What is my medical provider's relationship with Medicare?

Often times it can be confusing to Medicare beneficiaries just how much of their medical expenses will be covered and for how much they will be responsible. This, in part, can be due to not understanding their providers’ relationship with Medicare.

Medical providers are categorized under three classifications in reference to Medicare. They are: providers who accept assignment, providers who do not accept assignment, and opted-out providers.

Providers who accept assignment (also known as participating providers) will accept Medicare patients, bill Medicare for their services and products, and accept the Medicare-approved amount as payment for their services. The providers will submit a claim to Medicare for 80% of the cost of their services and Medicare will pay them directly. The beneficiary is responsible for the annual Part B deductible and the other 20% unless they have a supplemental coverage. There are certain Medicare providers who must accept assignment. This includes clinical social workers and physician assistants

Providers who do not accept assignment (also known as non-participating provides) will see Medicare patients and will submit the claim for their services to Medicare, but do not agree to accept the Medicare approved amount as payment in full. They can charge a limiting fee of up to 15% more than what Medicare will pay and the beneficiary is responsible to pay that additional 15%. They can also request that the beneficiary pay the entire amount up front and then Medicare will reimburse the beneficiary. The limiting charge rule does not extend to durable medical equipment (DME) such as wheelchairs, walkers, diabetic testing supplies, oxygen or C-PAP machines. It is a good idea to check your Medicare Summary Notice when it arrives every three months if you have had claims paid by Medicare to ensure that Medicare has paid correctly. There are some states that have set a cap on the limiting charge. New York limits the amount to 5% rather than 15%. There are some supplemental plans available that will cover this extra amount.

Opted out providers have agreed to be excluded from the Medicare program. They can charge whatever amount they want for their services and products and have no ability to submit claims to Medicare. If you utilize this type of provider, be prepared to sign a contract that describers the charges and states that you are agreeing to pay in full for any services or products you receive. You will not be able to pay up front and then submit a claim to Medicare on your own. If you have a supplemental plan, they may not pay either. Most supplemental plans are designed to pay the remaining amount after Medicare has paid. An example of opted-out providers are many psychiatrists.

It is important to know the status of your provider’s relationship with Medicare as it can make quite a difference in any amount you may owe. When making an appointment to see a new provider, always ask if they are a participating, non-participating or opted-out provider.

Providers who contract with Medicare have one calendar year from the date your services were provided to submit the claim. Beneficiaries should watch their Medicare Summary Notices (MSN) closely to make sure the claim has been submitted in a timely manner. If more than a year goes by before the submission to the Medicare Administrative Contractor (MAC), the provider will be unable to bill Medicare for their services. They can still, however, charge you the remaining 20% and any deductible amount that applies.

The MAC is a private health insurer that Medicare has contracted with to provide claims processing. The MAC that services Alaska is Noridian Healthcare Solutions LLC. You may notice their logo on the envelope that contains your Medicare Summary Notice. Your Medicare summary notice is not a bill. It is the explanation of how Medicare processed your claims and notification if there is any amount you may owe. They are sent out quarterly and will inform the beneficiary of the three month span that they have paid claims. If you desire to know more quickly the status of your claims, you can go to mymedicare.gov. You can set up your own confidential site within Medicare to view your claims status. When a claim is processed on your behalf, it is available for review within 24 hours.

If you are interested in learning more about how to read your Medicare Summary Notice, the Medicare Information Office at the Anchorage Senior Activity Center is offering a class on March 12 from 10 to 11:30 a.m. If you would like to attend, please RSVP by contacting Nila Morgan at 907-770-2070.

If you have questions about the status of a provider, you can call the provider’s office and ask, use the Medicare Provider look up tool at Medicare.gov – the national website for Medicare or call the Medicare Information office for assistance.

Author Bio

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Nila Morgan is a Certified Medicare Counselor who works at the Anchorage Senior Activity Center.

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