Medicare approved amount vs. Medicare paid amount, what's the diff?

[Todd King]

Todd,
I have happened to be able to see another Medicare EOB (sorry I forget the right technical term) from a different local hospital chain. It does exactly the same thing.

Facility Charge $11,733
Medicare Approved $11,733
Medicare Paid $833
Amount you may owe $212

I am wondering if the "approval" of the entire amount relates to other types of payments Medicare may be making to (at least some) hospitals beyond the payment directly on behalf of the Medicare Beneficiary.

Just wanted to let you know my personal billing and EOB a couple of years ago was not a unique situation with our local hospitals.

This EOB came straight from Medicare?

 

[LostDollar]

This EOB came straight from Medicare?

Yes.
5 page Medicare Summary Notice dated Dec 26, 2019.

(This one is from our local Catholic hospital chain. Mine, a couple of years ago, was from the local Wesley hospital.)

I'll get some claim amount and note information goillini asked about later tonight.

 

[Todd King]

Okay, so that came from you local hospital. I couldn't begin to explain what they do. I was wanting to see if it came straight from Medicare (CMS).

 

[LostDollar]

I was wanting to see if it came straight from Medicare (CMS).

Yes, it did.

This is NOT a bill from the hospital. It is the official Medicare "EOB" (MSN) showing how Medicare processed the claim. The provider is a local hospital, not an individual provider like a doctor or optometrist. In the hospital's case, Medicare allows the complete charge, but only pays a small portion. In the case of other providers, Medicare only allows a small portion of the provider charge and pays approx 80% of that.

 

[ICACharleston]

Why not obscure the patient’s name and scan the document then put it up here so we can see it?

 

[LostDollar]

Ok, I think I finally have an idea about what is going on.

It is based on a concept I found in this article:
Medicare Payments for Outpatient Therapy

My idea is vague. It centers around the concept that Hospital OutPatient Billing Departments that do not accept assignment are apparently not subject to limiting charges like individual providers, such as doctors.

So the MSN (i.e. Insurance Company EOB), in "allowing" the full billing, becomes an authorization for the Medicare Part B service provider to bill the Medicare Beneficiary for all of the provider charges not paid by Medicare, IF the provider (hospital facility) does not accept Medicare assignment.

The MSN would look similar to pages 1 and 5 of this document,
https://www.cms.gov/Medicare/Medica...ads/Sample-Part-B-Medicare-Summary-Notice.pdf

Except it would say Facilities with Claims This Period on page 1 and the two left hand amount columns on page 5 would be equal as I showed in a post above.

 

[bpenn9]

I logged back into this forum and Lost Dollar is still here clogging things up! What a shame.

 

[LostDollar]

I logged back into this forum and Lost Dollar is still here clogging things up! What a shame.

Hang around. You may learn something.

 

[somarco]

I logged back into this forum and Lost Dollar is still here clogging things up! What a shame.

See what you have missed?

So many posts.

So little time.

 

[LostDollar]

@Todd King
@goillini52
@ICACharleston
Thank you for your comments and questions. I have not posted the other info asked for because I think I finally came up with what is going on.

I tried to put the information below in a neat short table, but the post box doesn’t accept spaces in lines.

The MSN claim information from the two Part B Facilities Claims is listed below.

What I believe these are, are “Messages From Medicare” in regard to Excess Charges.
===========================================================
I think this one says the hospital Part B outpatient billing department could bill the (out)patient $27,110.40 in excess charges if they do not accept assignment.
-------------------------------------------------------
Amount Facility Charged..... $ 29,718.51
Medicare Approved Amount $ 29,691.94
Amount Medicare Paid.......... $ 2,035.67
Maximum you May Be Billed ....$ 545.87
============================================================

I think this one says the hospital Part B outpatient billing department could bill the (out)patient $10,688.75 in excess charges if they do not accept assignment.
-----------------------------------------------------------------------
Amount Facility Charged..... $ 11,733.66
Medicare Approved Amount $ 11,733.66
Amount Medicare Paid .............$ 832.53
Maximum you May Be Billed.... $ 212.38
========================================================

@MBSC
If you see this and care to respond, do you think I have made a correct interpretation above?