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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

If you’re looking for the best Medicare supplement plans, MedicareFAQ can help. Our licensed Medicare agents are well-versed in all available plans and carriers to ensure you receive the best coverage possible for your needs. We help you compare carriers and policies to find coverage that is right for you.

Additionally, when you have a policy through us, our client care team can help you with any policy issues or inconveniences, making the process as smooth as possible. Give us a call or fill out our rate comparison form to get started.

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/
David Haass

David Haass

David Haass is the Chief Technology Officer and Co-Founder of Elite Insurance Partners and MedicareFAQ.com. He is a member and regular contributor to Forbes Finance Council and stay up-to-date with the latest Medicare trends and changes. He holds a Bachelor of Science in Business Administration and Management from the University of Florida.

44 thoughts on "Medicare Reimbursement"

  1. I need to file 7 claims for acupuncture treatments for back pain. May I submit/attach all seven with one Medicare Claim form

    1. Hi Sandra, Medicare will reimburse you if you 1.) receive a prescription from a doctor stating the lift is medically necessary. 2.) Purchase the chair lift from a Medicare-approved supplier. and 3.) submit a reimbursement form to Medicare directly. Hope this helps!

    2. Will medicare reimburse me for power wheel chair prescripted for by my doctor’s prescription and I have seen doctor face to face for his decision on prescripting the wheel chair. I tried to get prior authorization but impossible to get thru to medicare or help from medical supply places. Nancy Lambert

      1. Hi Nancy! If you have a prescription from your doctor for a power wheelchair, then yes, Medicare Part B will cover it as durable medical equipment. You would have to talk to your doctor or the wheelchair supplier to put in a prior authorization request to Medicare. Also, the supplier for the power wheelchair must be approved to accept Medicare in order for you to get coverage for it.

        Your power wheelchair may not even need prior authorization. You may just need a signed order from your primary care doctor to get coverage for the power wheelchair.

  2. Hello,
    If a pt who has a knee replacement buys his own rolling walker and he has medicare can he be apply for reimbursement?

    1. Angel, if the walker can be deemed medically necessary by his physician and the walker was purchased from a medicare participating supplier, a reimbursement claim can be made.

  3. My son is having cataract surgery tomorrow Nov 3 and Nov 4th 2021. the surgeon and surgery center do not take his insurance. He has Gateway Health Medicare Assured Diamond and the Access. he is handicap with epilepsy and cerebral palsy. We need to pay both bills up front and he was not accepted by Care Credit. After the surgery can I send in all the bill for reimbursment.?

    1. Hi Robin, unfortunately, if the facility does not accept his insurance and you paid up-front, you’ll likely face denial if you try to submit for reimbursement. We apologize for not being able to address your comment sooner and wish your son the best in recovering from his surgery.

  4. My husband made a cancer treatment with a doctor who dont acept Medicare. We paid out front for a full bill(+ than 8000).Can aclaim be filled for reimbursement?

  5. Hello, I was unaware due to traumatic event this February, that I dislocated my shoulder on dominant hand while I was drowning. After a month I started to notice my body’s severe reactions to it. I went to see a doctor who ones helped me, but doesn’t take Medicare. After 2 month of treatments it became clear I have an injury. I called my insurance but they say there’s nothing they can do if I paid in front and didn’t call them before. I feel like this situation is unfair, it was already stressful enough and I had to spend tons of money to get immediate help and attention. And my insurance would refer me to places with 2 month of waitlist. Are there claim I can file in such case? Does Medicare cover an incident as severe as that? Thank you

      1. Lia, Apple Health is not a part of Medicare. Parts of Medicare include Part A, Part B, Part C, and Part D. If you were not enrolled in one of these parts during the time of the incident, Medicare won’t cover it.

  6. Hi, I’m having difficulty finding an acupuncture practice that accepts Medicare where I live; do you have any suggestions I can pursue? Thanks!

  7. Can my mother get reimbursed for mental health services paid for out of pocket with an LCSW who does not accept Medicare?

  8. I broke my foot and Dr gave me RX for foot scooter. Medial supply will not submit to Medicare. I bought one on Amazon. What do Ido to get reimbursement?

    1. Hi Pat! You would need to purchase the foot scooter through a Medicare-approved provider to get reimbursed.

  9. Hi I went to start a suboxone program but they say they accept Medicare but I have to submit for reimbursement so they’re asking me to pay the $199 for first month and send in for reimbursement. I have original Medicare does this sound rt. I can’t afford to pay the $199 and then get it denied for reimbursement thanks.

    1. Hi, jeff! If they accept Medicare they should be billing Medicare directly. Any unpaid balance left after Medicare pays their portion would then go to your supplement plan. If you do not have a supplement plan, the balance would be sent to you.

  10. I bought a pair of walking shoes and was told that this style as recommended by my foot Dr may be eligible for Medicare reimbursement. It showed 3 styles are Medicare/HCPCS code =A5500. What do I next.

  11. Hello,
    I was charged a copay from CVS for my immunosuppresent drugs of which are covered under my Medicare Part A….I was told they entered the wrong code and this is why there were costs associated. How do you file a claim to get reimbursed

    1. Hi Lee! You would need to complete form CMS-1490S and submit it to Medicare. You can also do this through your MyMedicare account online. Make sure to get an itemized bill from your provider.

  12. Hi, Can you please tell me what form I need to fill out to get reimbursed for durable medical supplies.

    Thanks

    1. Can someone send me a form so I can get reimbursed for medical treatment at my local walk in clinic I had to pay upfront – they gave me a form all filled out with all the info about the visit and told me to file with my insurance people they don’t do that thanks Mary Romeo

      1. Hi Mary! The form is linked in the content, you can download it from there. The form has the mailing address to mail the form too. You can also log into your MyMedicare account and possibly submit it there vs mailing it in.

  13. Hello, I had to buy my own oxygen concentrator and portable concentrator. Shortly after received a Medicare covered diagnosis. Am I able to be reimbursed?

    1. Hi Laura! If you had Medicare at the time you purchased the oxygen concentrator, you should be eligible for reimbursement.

  14. 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

    1. Hi Isidro! Unfortunately, Medicare does not travel with you. It’s only meant to be used in the United States. The only time you can get coverage outside the United States is with a Medigap plan, and it only covers foreign travel emergencies.

  15. 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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