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Medicare Reimbursement: How It Works

Medicare-Reimbursement-How-It-Works

If you are new to Medicare, you might think that all you have to do is to walk into a provider’s office and show your red, white and blue identification card to receive care.

Most of the time, Medicare beneficiaries are required to make deductible, coinsurance or copays.

However, there may be situations where it’s necessary to pay for services up front and then submit a claim to Medicare. In this article, we’ll explore how Medicare reimbursement works for various types of care.

The Medicare payment process

You can be seen by any physician you want. However, he or she may or may not be a Medicare participating provider.

If they are, your provider has agreed to accept the rate Medicare sets for the services they offer.

Typically, after you visit a physician or other healthcare provider, they will bill Medicare. Medicare, in turn, pays the agreed-upon rate to that provider. You, the patient, contribute any out-of-pocket costs.

Non-participating physicians

Then there are some doctors who see Medicare patients, yet do not agree to accept Medicare rates.

Some may charge you the rate set by Medicare, or they may add an additional cost above the Medicare rate. In addition, they could bill Medicare themselves, or require you to pay them at the time of service. In this case, you’ll need to file a claim for Medicare reimbursement.

Original Medicare (Parts A and B)

With Original Medicare, Part A covers hospitalization and Part B covers physician visits and outpatient care.

Part A expenses are covered by Medicare if you seek care from a participating provider. If, for some reason, the provider doesn’t bill Medicare and you are billed, you’ll need to file a claim. This also applies for Part B.

If you travel out of the country, remember that Medicare does not cover services except in certain instances.

For example, it’ll cover emergency treatment if an American physician or treatment center isn’t nearby. Medicare considers such claims on a case-by-case basis.

Medicare Advantage (Part C)

Also called Part C, Medicare Advantage (MA) is private insurance, unlike Parts A and B. Beneficiaries can use MA to add prescription drug, dental and vision coverage to their Part A and Part B coverage.

Medicare pays these private insurers monthly. Therefore, claims for MA plans are not filed with Medicare. They’re filed with the insurer directly.

Depending on if you choose a Part C HMO or PPO, you may see in-network or out-of-network providers.

If you choose an out-of-network provider, you’ll probably have to file a claim for Medicare reimbursement.

Medicare Part D

Like MA plans, prescription drug coverage – Part D – is also provided by private insurance companies. They can vary somewhat on what medications they cover. Each has a formulary – a list of four tiers, ranging from the lowest cost for generic drugs, to the highest cost for expensive prescription medications.

Remember that Part D plans can change up their formularies, but generally will give members notice that a medication they are taking will be affected.

As with Part A, Part B, and Medicare Advantage, the provider – a retail or mail order pharmacy in this case – generally files claims on behalf of the beneficiary.

And you can’t file a claim with Medicare directly because Part D plans, like MA plans, are managed by private insurers. You’ll have to file any claims with them.

Medicare reimbursement summary

Most of the time, Medicare beneficiaries won’t need to file claims for Medicare reimbursement. The providers will bill Medicare directly, and they’ll only need to pay any applicable deductible, copayment or coinsurance payment.

But in some cases, those with Part A (hospitalization) and Part B (doctor visits) may find themselves in circumstances where they pay up front for healthcare services. These patients will need to file claims with Medicare.

Medicare reimbursement forms are available in English and Spanish. Be sure to include an itemized receipt from the provider listing all the services provided, along with any additional supporting documentation.

Learn More: Coordinating Medicare and COBRA

People Also Read: Medicare Covers the COVID-19 Vaccine at No Cost to You

Meet Melissa MacCalla

Medicare is not simple and can be hard, frustrating, and downright confusing for most. I love when I get someone on the phone and I am given the opportunity to explain the difference in plans to them and have Medicare make sense. I enjoy talking to clients year after year, hearing about their families growing or them asking about mine.

-Melissa

Senior Healthcare Solutions, you truly stand out from most other insurance agents. Thank you so much for all of your help and I know that you will have nothing but success with how you conduct business.

Joan B.

Montgomery, AL

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