Medicare Supplement Insurance Claim process

[somarco]

Pretty (city) girls just seem to find out early, how to open doors with just a smile . . .

 

[NewBeeCA]

EOB comes from the carrier after the claim is paid.

Beneficiaries receive the MSN from Medicare but that is usually long after the claim has been paid by Medicare and the Medigap plan.

Also, there is virtually no paperwork with regard to Medicare/Medigap. Claims are filed electronically with Medicare who adjudicates the claim then sends it to the Medigap carrier (in most situations) via crossover.

Very few OM claims require prior authorization which is usually handled electronically as well.

Providers are very much aware of how claims are handled. However their office staff is often clueless about the difference in OM vs managed care.

Thank you so much for the detailed reply. Really appreciate it.

I have a follow up then. If a provider's office says they don't accept XYZ Medigap plan, what is one to do? Can they just tell the provider they are just on Original Medicare and let Medicare forward the claim to the Medigap carrier?

It doesn't make sense for a provider to accept a Medigap plan from one carrier and not all the others.

Thanks again in advance for all the help.

 

[NewBeeCA]

(I use MEOB below because that is what my Medigap carrier uses.)

Caveat, not an agent.

On my claims, claims from Part B hospital providers have been treated differently from other Part B claims.

For my non-hospital Part B providers, the Medicare claim -- if and when approved -- is forwarded to the Medigap carrier.

For Hospital Part B claims, there are two differences on the MEOB.

1) If the service is approved by Medicare then the Medicare Approved Amount in column 3 of the MSN/MEOB is shown as 100% of the Hospital Part B provider's charge.

2) For the Hospital Part B provider, the claim is NOT automatically forwarded to Medigap. You can see this clearly from my MEOB's, all the non-hospital provider claims have the crossover footnote, the Hospitals do not.

This is not a one hospital or one year claim abberation. I have had that happen with one hospital's claims in two separate years. I have also had that happen with two different hospital's claims in the same year.

There appears to be some distinction in the claims process for Part B hospital providers,

Thank you for the detailed reply, It is very helpful.

NewBeeCA

 

[renee15]

EOB comes from the carrier after the claim is paid.

Beneficiaries receive the MSN from Medicare but that is usually long after the claim has been paid by Medicare and the Medigap plan.

Also, there is virtually no paperwork with regard to Medicare/Medigap. Claims are filed electronically with Medicare who adjudicates the claim then sends it to the Medigap carrier (in most situations) via crossover.

Very few OM claims require prior authorization which is usually handled electronically as well.

Providers are very much aware of how claims are handled. However their office staff is often clueless about the difference in OM vs managed care.

Medicare sends out quarterly reports of claims, so much time has elapsed. The carrier sends out EOBs whenever they feel like it. (UHC) I have a March DR appt that hasn't shown up anywhere still...

 

[somarco]

If a provider's office says they don't accept XYZ Medigap plan, what is one to do? Can they just tell the provider they are just on Original Medicare and let Medicare forward the claim to the Medigap carrier?

Technically, they can't do that.

If they participate in OM they must accept all Medigap plans. I presume someone at the provider office does not understand the difference in Medigap and Advantage.

The patient can only present the Medicare card and be done with it. The provider is not allowed to submit claims direct to the Medigap carrier . . . even if they did, the claim would not be processed since it did not go through Medicare.

I have a March DR appt that hasn't shown up anywhere still...

Not even in your MyMedicare account?

 

[NewBeeCA]

Technically, they can't do that.

If they participate in OM they must accept all Medigap plans. I presume someone at the provider office does not understand the difference in Medigap and Advantage.

Thanks! What is happening here is that the larger providers like Sutter Health are trying to steer people towards MAPD plans. They "accept" medigap plans for existing patients, but are saying they won't take them for new patients. It does not make sense.

NewBeeCA

 

[somarco]

What is happening here is that the larger providers like Sutter Health are trying to steer people towards MAPD plans. They "accept" medigap plans for existing patients, but are saying they won't take them for new patients. It does not make sense.

I believe providers in The Villages (FL) are doing something similar.

I guess as long as no one complains they can get away with it . . . even if they are not supposed to.

 

[rmhaire]

echnically, they can't do that.

If they participate in OM they must accept all Medigap plans. I presume someone at the provider office does not understand the difference in Medigap and Advantage.

The patient can only present the Medicare card and be done with it. The provider is not allowed to submit claims direct to the Medigap carrier . . . even if they did, the claim would not be processed since it did not go through Medicare.

Agree.

And part of the problem is that doctors that ask this stuff don't really understand exactly how Medicare works.

Back in the mid 90's several major changes were made to just how doctors get paid.

In the old days Medicare sent their payments to the beneficiaries. That changed.

They also did away with the bulk of excess charges. Now doctors can charge up to 15%. And even that is not a true 15%. It's not 15 % of the medical bill but 15% of what Medicare approves.

Bottom line, any doctor or provider that asks for anything more that your Medicare card simply doesn't understand how this stuff works.

 

[LostDollar]

I have a March DR appt that hasn't shown up anywhere still...

Not even in your MyMedicare account?

Caveat, I am not an agent.

Note: I have an HDF medigap - so the billing chain for a medical service is of a little more interest to me than it might be for some.

@renee15 -- what somarco asked. Off the top of my head, I think every Part B service I have received in the past 3 years has shown in my MyMedicare account within 2 months of the date of service. That becomes my control map for monitoring Medigap processing and subsequent provider billings.

However, if providers have 18 months to submit a bill to Medicare, it is now (after some years of being on medicare) entirely believable to me that a provider could have some kind of billing problems and not get a bill submitted to CMS, in what you and I might consider to be a timely manner.

You obviously have computer access. If you don't have a MyMedicare account, please do yourself a favor and get one. This will allow you to monitor activity in your account.

If the bill doesn't show by September, you can make your own decision on whether or not to bring it up to your provider. Personally, if I was in this situation and had a regular Plan G or F, I think I would lean toward leaving the situation alone until, or unless, the provider came after me for payment or denied service because of unpaid bill on my account.

 

[LostDollar]

The patient can only present the Medicare card and be done with it.

Bottom line, any doctor or provider that asks for anything more that your Medicare card simply doesn't understand how this stuff works.

Caveat, not an agent.

I have never been able to make somarco's process of submitting only a Medicare card work.

The billing people at most of my Part B providers understand exactly how the process works, but they do insist that I provide both my Medicare and Medigap cards. I have so many things I can stamp my foot and loose my temper about, this one is not worth the trouble since I have, and always carry, both cards.

(Billing person at a now retired doctor's office once told me she wanted to be able to track the progress of billing and payment.)