Why Is Medicare Denying Paying for My Doctor Visit?

Hello Toni:

I have a $900 doctor bill with a new cardiologist and Medicare says they will not pay?     I recently retired and enrolled in Medicare and a Medicare supplement for the freedom to pick my own doctor!

This is too confusing for me. I need some advice…Thanks, Jane from Houston, TX.

Hello Jane:

I rarely see a problem with doctor’s/provider’s bills, but when it does happen, there is a process you must do to find out if the office visit or procedure will be paid as a “Medicare approved” service.

If Original Medicare will not pay for the care you received, you will find this out when you receive your Medicare Summary Notice (MSN). The MSN is a summary of claims for health care services Medicare processed for you during the previous three months. The MSN is not a bill. Medicare Summary Notices (MSNs) are mailed four times a year and contain information about submitted charges, the amount that Medicare paid, and the amount you are responsible for. MSNs are used only with “Original Medicare” and not with a Medicare Advantage or Medicare Part D Prescription Drug Plans.

 Below is what you should do if you believe the claim is medically necessary:

• Find out if it is possible that there was a billing mistake. Medicare uses a set of service codes, called CPT codes, for processing medical claims. Each medical service has been assigned a specific code. Sometimes providers accidentally use the wrong codes when filling out Medicare paperwork, and this can result in Medicare denials. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct codes. Your doctor’s billing office can call 800-MEDICARE (800-633-4227) to get in touch with the company that processes Medicare claims if the wrong code was used, ask your doctor to resubmit the claim with the correct code.
• If the provider believes that the claim was correctly coded or is unwilling to refile the claim, your next step is to appeal. Appealing is easy and many Americans win! The MSN will have instructions for how to appeal. Follow these instructions or call 1/800-MEDICARE for help. If the MSN lists several items and you are not disputing all of them, circle the one you want to appeal. Write “Please Review” on the bottom and sign the back. Make a copy for your files. Then mail the signed original to Medicare at the address on the MSN. Make sure you mail your appeal within 120 days of receiving the MSN. Do NOT wait past the time to appeal!
• If possible, get a letter from your health care provider saying that you needed the service and why. Send this with your MSN.

**Always keep photocopies and records of all communication, whether written or oral with Medicare concerning your denial. Send your appeal certified mail and make sure you ask the post office or UPS/FEDEX for signed delivery confirmation. **

For information about specific Medicare questions, email info@tonisays.com or call 832/519-8664 to have your Medicare questions answered.

Toni King, Medicare author/advocate is giving a $5 discount to the Toni Says® readers on the new 2021Medicare Survival Guide® Advanced book at www.tonisays.com.