What to do if Medicare thinks you have other insurance | News, Sports, Jobs

Question: I recently received a Medicare Summary Notice (MSN) stating that Medicare will not pay my test bill. When I contacted the provider to ask questions, they told me: “Medicare thinks you have other insurance.” That I have to do? Do I have to pay this bill?

Answer: I don’t think I should pay this bill.

This could be one of two common reasons. First reason: you have Medicare and Medicare “think” you have another type of plan ahead. Second reason you have Medicare and joined the Medicare Advantage Plan

I covered the first reason in last week’s article. This week I will address the second; You have Medicare A & B and joined a Medicare Advantage Plan.

In this situation, you already have Medicare A and B, AND you have joined a Medicare Advantage Plan that is opposite Medicare A and B. Medicare will not pay for any of the services and procedures because the Medicare Advantage Plan is financially responsible. for these claims. Many people who join Medicare Advantage Plans don’t understand this relationship. You must have Medicare A and B, so you pay the Part B premium ($170.10 per month for most), but Medicare doesn’t pay your medical bills. When you sign the contract/enrollment agreement with the Medicare Advantage (MA) plan, you agree that the MA plan will pay for your health care needs. This settlement requires different procedures for claims to be paid. The different procedures could include referrals to specialists, prior approval for treatments and tests, or regional restrictions on your care. This is different from Medicare. Original Medicare Parts A and B work anywhere in the country, without permission, without the need for referrals. Medicare Advantage plans sometimes restrict your access to health care providers or require prior approval before procedures are performed.

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In this situation, members show their Medicare Card and their Medicare Advantage Plan card. The bill may go to Medicare in error and Medicare will deny the claim (bill) because the MA Plan is responsible for processing the claim. If the medical provider submits the claim to the correct MA Plan, the claim will be processed according to their procedures and ideally paid. You may have a copay amount for the procedure, but the insurance company will help pay for the cost of the procedure.

If this is your situation, correcting the problem may simply require you to call your provider and speak with the billing department, to clarify that the MA Plan should be billed first and only. Medicare will not pay the claim in this situation. This could be called a Coordination of Benefits issue, but it doesn’t have to involve Medicare’s Coordination of Benefits department. It can usually be cleared up with a quick phone call from you to your provider.

MA Plans come in many different types and different benefits. The types are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), or Private Fee-for-Service (PFFS). Each of these plans is a replacement for Medicare. You must have Medicare A and B to join the plans, but once you join an MA Plan, Original Medicare A and B won’t cover your medical expenses.

If you’re not sure what your insurance is, take a look at your cards, you may see some of these abbreviations on the front of the card. Otherwise, call the customer service number on the back of the card to ask what your coverage is or how it works. You can also call 1-800-Medicare and ask what Medicare thinks you’re signed up for and that can help too. The www.medicare.gov website is also a tool you can use, although it won’t help you keep track of claims and bills, since Medicare won’t have those records. Your Medicare Advantage Plan (insurance company) will have those records. The www.medicare.gov website will indicate which insurance Medicare thinks is your primary insurance.

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Senior Life Matters is a community-based program sponsored by Lutheran Jamestown. For questions, concerns, or to contact Janell Sluga, GCMC, please call 716-720-9797 or email [email protected]

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