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Medicare Reimbursement


Medicare Reimbursement may be necessary if you pay a claim that should’ve otherwise had coverage. While it’s not common to need reimbursement, things happen. Mostly, doctors handle the Medicare billing process for you.  But in a few situations, you may have to pay for your care up-front and file a claim asking Medicare to reimburse you. The claims process is simple, but you will need an itemized receipt from your provider.

What is Medicare Reimbursement?

If you’re on Medicare, your doctors will usually bill Medicare for any care you obtain. Medicare will then pay its rate directly to your doctor. Your doctor will only charge you for any copay, deductible, or coinsurance you owe.

In certain situations, your doctor may ask you to pay the full cost of your care–either up-front or in a bill; this might happen if your doctor doesn’t participate in Medicare.

If your doctor doesn’t bill Medicare directly, you can file a claim asking Medicare to reimburse you for costs that you had to pay.

How Does Medicare Reimbursement Work?

Medicare allows you to see any doctor you choose, but that doesn’t mean all providers handle billing in the same way. Medicare has a schedule of rates it will pay for its covered healthcare services. Those rates are typically much less than a private insurance company would pay.

Most healthcare doctors are “participating providers” that accept Medicare assignment. They have agreed to accept Medicare’s rates as full payment for their services.

If you see a participating doctor, they handle Medicare billing, and you don’t have to file any claim forms. However, certain doctors don’t bill Medicare directly.

If you want Medicare to pay for your care, you’ll need to send a form to request reimbursement.

Seeing a Non-participating Doctor

These doctors accept Medicare patients, but they haven’t agreed to Medicare’s rates. They may choose to accept Medicare rates in your case, or they may decide to bill you up to 15% more than the Medicare rate. The extra charge is an “excess charge.” Non-participating doctors may bill Medicare directly. But they may also ask you to pay up-front and seek reimbursement from Medicare.

Foreign Travel Care Reimbursement

Receiving care outside the United States that is covered by Medicare. In general, Medicare doesn’t pay for services in foreign countries. But there are a few exceptions where you can file a claim and get reimbursement for your costs.

Improper Provider Billing

Buying durable medical equipment such as a wheelchair or walker, and the equipment supplier does not bill Medicare. Your doctor never sent your claim to Medicare. Medicare will pay claims for a year from the date of service.

If you are close to the deadline, you can seek reimbursement.

Part A Reimbursement

Part A covers doctors, equipment, medications, tests, and other services you receive as an inpatient at the hospital. It also covers a limited amount of time in a skilled nursing facility after a hospital stay, hospice care, and home health care.

Your doctors will usually bill Medicare, which covers most Part A services at 100% after you’ve met your deductible.

However, occasionally you may receive a surprise bill from a doctor that was involved in your inpatient treatment.

If this happens, contact the doctor and find out if they accept Medicare assignment and if and when they plan to submit the claim to Medicare.

If they do not intend to submit the claim, request an itemized receipt so you can file a request for reimbursement.

Medicare Reimbursement for Physicians

Doctor visits fall under Part B. You may have to seek reimbursement if your doctor does not bill Medicare. When making doctors’ appointments, always ask if the doctor accepts Medicare assignment; this helps you avoid having to seek reimbursement.

Be aware that some doctors have opted out altogether, and Medicare won’t pay for any portion of their services.

Finding the Medicare Reimbursement Form

The Medicare reimbursement form, also known as the “Patient’s Request for Medical Payment,” is available in both English and Spanish on the Medicare website.

How to Get Reimbursed From Medicare

To get reimbursement, you must send in a completed claim form and an itemized bill that supports your claim. It includes detailed instructions for submitting your request. You can fill it out on your computer and print it out. You can print it and fill it out by hand. The form asks for information about you, your claim, and other health insurance you have.

The itemized bill must contain the following information:

  • Date of service
  • Place of service
  • The charge for each service
  • Description of your illness or injury
  • Description of the medical and surgical supplies
  • The name and address of the doctor or supplier
  • The doctor or supplier’s National Provider Identifier Number, if you know it.

For some claims, the bill must also include the name of the ordering and referring doctors.

Send the claim form, bill, and any other documentation to the correct address for your state. Mailing addresses are on the last pages.

Medicare Advantage Reimbursement

If you are in a Medicare Advantage plan, you will never have to ask for reimbursement from Medicare. Medicare pays Advantage companies to handle the claims. In some cases, you may need to ask the company to reimburse you. If you see a doctor in your plan’s network, your doctor will handle the claims process.

Your doctor will only charge you for deductibles, copayments, or coinsurance. However, the situation is different if you see a doctor who is not in your plan’s network.

Coverage for out-of-network doctors depends on your Medicare Advantage plan. Many HMO plans do not cover non-emergency out-of-network care, while PPO plans might.

If you obtain out of network care, you may have to pay for it up-front and then submit a claim to your insurance company. The process for doing this varies depending on your insurance company and plan.

Part D Reimbursement

Part D is prescription drug coverage provided by private insurance companies. These drug companies establish their own rules about which drugs are covered and what you will pay out-of-pocket.

In general, pharmacies handle the insurance process, and you will only pay a copay or coinsurance on the medications you take. If the pharmacist tells you a drug is not covered, or if the cost is higher than you think it should be, contact your prescription plan. You may need to file a coverage determination request and seek reimbursement.

FAQs

How long does reimbursement take?
It takes Medicare at least 60 days to process a reimbursement claim. If you haven’t yet paid your doctors, be sure to communicate with them to avoid bad marks on your credit.
How long does it take Medicare to pay a provider?
Medicare claims to providers take about 30 days to process. The provider usually gets direct payment from Medicare.
What is the Medicare Reimbursement fee schedule?
The fee schedule is a list of how Medicare is going to pay doctors. The list goes over Medicare’s fee maximums for doctors, ambulance, and more.

How to Get Help with Medicare Reimbursement

If you’re looking for the best Medicare supplement plans, MedicareFAQ can help. Our agents research multiple companies and policies to give you a quote that’s right for you. When you have a policy through us, our client care team can help you with any policy issues or inconveniences. Give us a call or fill out our rate comparison form to get started.

Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

8 thoughts on “Medicare Reimbursement

  1. wish to know that if I travelled and stayed in my country I could be reimbursed with Medical expenses, like Philippines? What is the best thing to do. member of Humana HMO, dual Medicare, Medicaid plan

  2. We paid $164,000.00 for life saving surgery to our surgeon and his in-house medical surgery center…Sent the itemized bill, was told that they don’t pay this Dr.. we know this, that’s why I wrote the check to the Dr.. very frustrated going around in circles….still not going ahead. We can appeal it before May 21, 2021….Not sure what to do or send..We have tri care. And Va…which will payout once Medicare does…So do I walk away go to tri care and Va or continue to battle Medicare

    1. Hi Deb. Did you confirm with the doctor prior to surgery if they accept Medicare? It sounds like the doctor does not participate in Medicare. When you have both Medicare and TRICARE for Life, Medicare is primary. So if the doctor does not accept Medicare, I don’t think you will be able to get reimbursed. However, 96% of doctors in the United States participate in Medicare. However, it works differently with Medicare Advantage. If you have a Medicare Advantage plan, that could explain why your doctor doesn’t accept it. Unfortunately, since TRICARE for Life is secondary, they won’t pay it unless Medicare pays their portion first. I’m sorry you’re finding yourself in this predicament. Your doctor really should’ve gone over the cost and your insurance options prior to performing the surgery.

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