Welcome to Medicare School Daily, where we help you understand Medicare, save money,
avoid mistakes, and above all else, get the most out of your Medicare benefits. Now, today's
topic is dealing with unexpected medical bills. None of us like unexpected medical bills.
We don't like surprises of any kind, especially when it comes to a medical bill that now we're
responsible for. And in my example today, we're gonna treat it as though you had a Medigap
plan G, meaning you bought a supplemental plan G, among the many options that are available
to you for med supp plans. Now, let's quickly review. If someone buys a Medigap plan G,
what are they going to be responsible for? So what this means is that when you enroll
in Medicare, you have chosen to stay in original Medicare A and B, which means that Medicare
A and B pays first. Okay? They are the first to pay the bills, and then you'll get some
sort of a supplemental plan that is then going to pay second. So the supplemental plans are
going to follow. And let's say in our example that we decide to buy that plan G - that's
the most common, most popular plan today. So when we buy a G, what's happening is Medicare
pays first; it is then followed by the G plan, followed by G. Right?
And so that G plan is going to pay second, and it's going to cover everything except
the B deductible. Every year, Medicare sets the B deductible; this year that happens to
be $198. Which means what? When someone buys a supplemental plan G, that G plan will pay
everything but the first $198 for the entire year. So that is going to be your responsibility.
But let's suppose that you get a surprise unexpected bill for $220. What's the first
question you want to ask? Have you met your Part B deductible yet? So let's suppose we
get that $220 unexpected bill, and we're looking at our explanation of benefits and we realize
that Medicare only paid $18. And we realize that our supplemental plan only paid $4. And
we see that our responsibility with that bill is $198. And so we look at the bill and we're
very disappointed. Medicare pays $18; my supplemental even pays less than that, and I’ve got this
$198.
What happened? More than likely, that is your deductible. You haven't met it yet for the
year, and so you're going to have to pay the $198. So the first $198 for the entire year
is your obligation. That could be the first $198 let’s say of an MRI or maybe a cataract
surgery. But the first $198 is going to find its way back into your mailbox in the form
of a bill. I had a lady recently tell me that she actually had five bills before she got
to the $198. She had a couple of doctor visits as well as some lab work. Finally got to her
$198. But once we've met that $198 B deductible, then we have 100% coverage medically as long
as Medicare is going to pay. That's all we have to pay. Everything else would be covered
after that. So that was question number one. Have you met your part B deductible? You're
responsible for that. Question number two is, was it coded correctly? Let's just suppose
that you have an outpatient procedure that was approved by Medicare for $1,000.
And again, you get an explanation of benefits and you're responsible for the full thousand,
because what it says on that explanation is that Medicare paid zero. Therefore, your supplemental
plan paid zero, and now you have to pay $1,000. Now, if you happen to be someone who works
with our firm, what would happen?
We would encourage you to call us. When you get some kind of a surprise unexpected bill,
let’s find out what happened. So they're saying you have to pay $1,000. So the first
thing we're going to do is we're going to ask you, is this something that was covered
by Medicare? And you say, well, absolutely it should have been covered by Medicare. So
what are we gonna do? We're going to actually call the provider, the doctor's office, or
maybe it was an ambulatory surgical center, outpatient center, a surgery center that did
this for this particular procedure. And they’re billing you. We're gonna call them and we’re
gonna ask them: Could you please go back and look at the claim that was made to Medicare?
Because we're getting a full balance on the bill. Will you make sure that it was coded
correctly? And so they'll pull the file up and they'll look at a claim and nope, usually
99 percent of time realize that they miscoded that. That's why Medicare denied the claim.
So if Medicare denied the claim, so did the supplemental plan. Remember, because it's
following Medicare. And that's why you have a bill for $1,000. So that's easily corrected.
The company, the provider, will actually correct the code. They will refile with Medicare.
Medicare's then going to adjust their payment, and it’s 80/20 on the Medicare side.
So we have Medicare is going to pay $800 of this claim, and your supplemental plan is
going to pay $200 of this claim. As it is originally for $1,000; we're assuming you've
already met your B deductible, and so it's going to look like this.
And so your responsibility is now going to be zero. So, again, if we have something that's
micoded, we may get an unexpected surprise bill. But again, that's a very easy correction,
correct the code, and you'll see the balance of yours will be brought to zero after you've
met your B deductible. And then that takes us to our third question we have to ask with
unexpected bills. And that is, was it a Medicare covered service?
Let's just suppose that we go to a chiropractor and let's suppose the chiropractor does an
adjustment to the spine, and that is billed at $40. And also, that chiropractor does an
x-ray, and that is billed at $125. And you also have acupuncture while you are there
at the chiropractor's office, and they bill that for $85.
Ok, so we have a total of services here at 250 dollars, but you get a bill from the chiropractic
for $210, and that is now your responsibility. And so let's suppose we've already met our
B deductible, and it was coded correctly. The problem in this scenario is what happened?
You got a service that was not covered by Medicare. What happened? The adjustment to
the spine is covered by Medicare, but x-rays are not, and nor would the acupuncture be.
They don't cover those kinds of services. So you would have a responsibility for $210
because those things are not covered by Medicare. And this is why we always encourage people
when they're on Medicare to always ask two questions. Number one, ask every provider
you go to, every doctor, every specialist, every hospital: Do you take Medicare? And
if we get a yes to that question, and that doctor is recommending anything beyond the
office visit, maybe a test or procedure or surgery, you’re always going to ask: Now,
is this going to be something that's covered by Medicare? Because, folks, if it indeed
is covered by Medicare, after you've met your B deductible of $198, it should be fully covered.
But if it's not covered by Medicare, whatever those services were, not approved by Medicare,
will be your financial responsibility. And so those are the three questions we ask when
we get one of those surprise bills. Have you met your part B deductible? You must $198
each year. Was it coded correctly? If it wasn't, that can be easily corrected. And you want
to be sure that everything you have done is a Medicare covered service or else you will
be responsible for the full balance of those services.