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Medicare Reimbursement


Medicare reimbursement may be necessary if you pay a claim out-of-pocket that should receive coverage through Medicare. While it is not common to need Medicare reimbursement, you still may find yourself in this situation.

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In most cases, your doctor or hospital will handle the Medicare billing process for you. But in a few situations, you may have to pay for your care upfront and file a claim, asking Medicare to reimburse you. The claims process is simple, but you will need an itemized receipt from your provider to proceed with the Medicare reimbursement process.

Keep reading to learn more about Medicare reimbursement, when you may qualify, and how to petition for reimbursement.

What is Medicare Reimbursement?

If you are on Medicare, your doctors typically bill Medicare for any care you obtain. Medicare will then pay its portion directly to your doctor.

Then, your doctor will only charge you for any outstanding copay, deductible, or coinsurance. If you have a Medicare Supplement (Medigap) plan, your Medigap plan will cover their portion of your bill after Medicare pays their portion.

In some situations, your doctor may ask you to pay the total cost of your care upfront or via a bill. These situations include if your doctor does not participate in Medicare or if Medicare does not cover the service you receive.

If your doctor does not bill Medicare directly, you can file a claim asking Medicare to reimburse you for out-of-pocket costs.

How Does Medicare Reimbursement Work?

Original Medicare (Part A and Part B) allows you to see any doctor you choose. However, not all providers handle billing in the same way.

Medicare assignment provides a list of rates that Medicare will pay for the healthcare services it covers. If your provider participates in Medicare assignment, you will know your exact costs before you receive coverage.

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Most doctors are participating providers that accept Medicare Assignment. They have agreed to accept Medicare’s rates as full payment for their services and will only bill you for the remaining deductible or coinsurance if necessary.

If you see a participating doctor, they handle Medicare billing, and you do not have to file any claim forms. However, some doctors don’t bill Medicare directly, so it is wise to speak with your doctor about their billing practices before receiving treatment. In this case, if you want Medicare to pay for your care, you must send a form requesting reimbursement.

Can I Be Reimbursed By Medicare for Seeing a Non-Participating Doctor?

A doctor who accepts Medicare patients but has not agreed to Medicare’s rates may charge you extra for care. In this case, they may choose to accept Medicare rates or decide to bill you up to 15% more than the Medicare rate.

The extra fee is known as an excess charge. Non-participating doctors may bill Medicare directly. Alternatively, they may ask you to pay upfront and seek reimbursement from Medicare yourself if you qualify.

The number of providers who accept Medicare but do not accept Medicare assignment is low. Thus, speaking with your provider beforehand is the best way to understand if you will encounter excess charges or not.

Medicare Part A Reimbursement

Medicare Part A covers inpatient hospital services, equipment, medications, and tests. This inpatient portion of Medicare also covers a limited amount of time in a skilled nursing facility after a hospital stay, as well as hospice care and home healthcare.

Typically, your doctors will bill Medicare directly. In this case, you may need to pay a deductible or coinsurance. However, you may occasionally receive an unexpected bill from a doctor 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 within 12 months.

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Medicare Part B Reimbursement

Doctor visits, durable medical equipment, and outpatient care fall under Medicare Part B. 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 of Medicare altogether, and Medicare will not pay for any portion of their services. Thus, ensuring your physician accepts Medicare before receiving services is essential.

Medicare Advantage Reimbursement

If you have a Medicare Advantage plan, you will never need to ask for reimbursement from Medicare. Medicare pays Medicare Advantage companies to process their claims independently.

Sometimes, you may need to ask your carrier to reimburse you, but never Medicare. If you visit a doctor in your Medicare Advantage 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 not in your plan’s network. In this situation, you could be responsible for up to 100% of the costs for an out-of-network provider.

Coverage for out-of-network doctors depends on your Medicare Advantage plan. Many Medicare Advantage HMO plans do not cover non-emergency out-of-network care. Yet, a Medicare Advantage PPO may provide you with some out-of-network coverage.

If you obtain out-of-network care, you may need to pay for it upfront and then submit a claim to your insurance company. This process varies depending on your insurance company and plan. Plus, there is no guarantee your plan will cover the visit.

Medicare Part D Reimbursement

Medicare Part D is prescription drug coverage through private insurance companies. These companies establish rules about which drugs receive coverage and what you will pay out-of-pocket.

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In general, pharmacies handle the insurance process, and you will only owe a copay or coinsurance on the medications you take at home. Contact your prescription drug plan if the pharmacist tells you a drug is not covered or if the cost is higher than anticipated. You may need to file a coverage determination request and seek reimbursement.

Where to Find the Medicare Reimbursement Form

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

How Do I Submit a Bill to Medicare for Reimbursement?

To receive reimbursement, you must send a completed claim form and an itemized bill supporting your claim. It includes detailed instructions for submitting your request.

You can fill it out on your computer and print it out or print it first and fill it out by hand. The form asks for information about you, your claim, and other health insurance you may 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
  • Name and address of the doctor or supplier
  • Doctor or supplier’s National Provider Identifier Number, if you know it

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

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

Medicare Reimbursement FAQs

How long does Medicare reimbursement take?
Medicare takes at least 60 days to process a reimbursement claim. If you have not 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?
Once your service is approved, 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 will pay doctors. The list reviews Medicare’s fee maximums for doctors, ambulances, and more.

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How to Get Reimbursed from Medicare

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Sources:

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. How Do I File A Claim, Medicare. Accessed August 2022.
    https://www.medicare.gov/claims-appeals/how-do-i-file-a-claim
  2. A Primer on Medicare: Key Facts About the Medicare Program and the People it Covers, KFF. Accessed August 2022.
    https://www.kff.org/report-section/a-primer-on-medicare-how-does-medicare-pay-providers-in-traditional-medicare/

Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

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