coordination of benefits Archives

Can Medicare Deny My Claims?

Medicare processes millions of claims each year, and some of them get denied. There can be any number of reasons why claims are denied, ranging from issues with billing codes to not meeting eligibility requirements. People make mistakes so billing errors can also happen. In these cases, beneficiaries can appeal the decision, or resubmit the claim. In order to avoid paying out-of-pocket unnecessarily, you should know the reasons why claims are denied and how to go about appealing denials.

Why Claims Can Get Denied

computer screen with codes on it. — *Your healthcare provider’s staff can make a mistake and put in the incorrect billing code.*

There are numerous reasons that a Medicare claim can get denied. These include:

Billing Errors– Your healthcare provider’s staff can make a mistake and put in the incorrect billing code for a service you have received. When this happens, medicare will deny the claim. For example, the “Welcome To Medicare” visit is covered 100%, but if the code put in reflects a normal visit, and not a covered wellness visit, then you will receive a bill in the mail.
Lack of Medical Necessity– Medicare requires doctors to provide proof that each service they provide is medically necessary. If Medicare does not deem a service necessary, then it will not cover the service. There may be times when a doctor will consider a service necessary for the patient’s needs, but Medicare might disagree and deny the claim. For example, a doctor may feel that blood work is necessary at a patient’s “Welcome To Medicare” visit. This service, however, is not generally covered by Medicare at this visit and so the claim will be denied.
Coordination Of Benefits– If a beneficiary has both an employer-based health plan and Medicare, then coordination of benefits is the process that determines which plan has the payment responsibility. Depending on the size of your employer, that plan will usually be the primary payer and Medicare will usually be the secondary payer. When you stop working or decide to drop your employer’s insurance, Medicare needs to be notified of the change. If Medicare is not notified by your employer, then Medicare will continue to be considered the secondary payer. Under these circumstances, any services you have that are billed to Medicare will be denied because they will still be considered the secondary payer.

Appealing A Medical Claim Denial

Denials for services that you feel should’ve been approved can be appealed. There are various legitimate reasons for appeal, such as billing mistakes. But there are limits on how long you have to file an appeal as well as procedures for how to file correctly.

When you get denied for a claim, you will receive a Medicare Summary Notice (MSN) listing the denied claim/s. You need to file your appeal within 120 days of receiving the MSN. First, you must circle the item that you are appealing on the MSN and then explain why you think it should be covered. Include any additional information supporting your appeal, including any supporting information from your doctor.

If your Medicare claim is denied, don’t panic. It could be a simple billing error. However, if you find you are receiving denials for services, make sure you are asking your healthcare provider about coverage at each visit. Your provider should be able to tell you what is covered and what is not and, if they can’t, they will need to provide you with an Advantage Beneficiary Notice of Noncoverage (ABN). This notice informs you that Medicare might not cover the claim, and if you agree to have services, then you agree to pay the non-covered charges. You then have the choice to either sign and receive the service or decline the service.

You can also call Medicare before receiving services to make sure they will be covered. And, if you do end up receiving a denial, you can always appeal it with supporting information. The more you know about how Medicare makes its decisions about coverage, the more likely you are to get the most out of your plan.

How Does Medicare Work With Other Insurance?

Are you over 65, working, and on your employer’s insurance? Are you looking into enrolling in Medicare as well? You can have both employer-based health insurance and Medicare at the same time, as long as you are eligible to collect Medicare. However, when it comes to paying for medical services, it can get a little tricky. There are rules for how Medicare and other insurance plans work together. One has to be a primary and the other a secondary insurance.

Coordination Of Benefits

number one and number 2 in list form — *Insurers will have a coordination of benefits to decide which insurance pays a bill first. There is a primary payer, and a secondary payer.*

Insurers will have a coordination of benefits to decide which insurance pays a bill first. Your “primary payer” will cover the maximum amount your plan allows first, then your “secondary payer” will step in and pay the rest, or as much as your secondary plan allows. The rule of thumb when you have both employer insurance and Medicare is: if the employer has 20 or more employees, then the group health insurance plan will be the primary payer. If the employer has less than 20 employees, then Medicare will pay first. There are a few things to know about primary and secondary payers:

The second payer might not pay the rest of the uncovered costs.
If your employer’s insurance is the secondary payer, then you may need to enroll in Medicare Part B before your employer’s insurance will pay. This is because when Medicare is primary to your other insurance, your other insurance may not pay for costs until Medicare pays. Part B will help you avoid paying high out-of-pocket costs for your care.

Conditional Payment

If your employer-based insurance does not pay for services such as workers comp or liability claims first, then Medicare will make the payment so you do not have to pay the bill out of pocket. This is called a conditional payment on Medicare’s behalf. It is considered conditional, because the payment has to be repaid to Medicare if you get a settlement, judgement, or other kind of payment later.

hand with pen checking off a checklist. — *There is a checklist you must meet in order to qualify for Medicare and other insurance.*

The Standard To Have Medicare & Other Insurance

There is a standard to meet in order to have Medicare alongside employer-based insurance. If you do not meet the standard, then there is a penalty. In order to have both and avoid a penalty from Medicare, you must make sure that:

You are enrolled into Medicare by age 65- Generally if you do not enroll into Medicare Part B within the 7 month initial enrollment period (6 months before your 65th birthday, the month of, and 3 months following), you will face a lifelong penalty.
You are working and covered by your employer’s insurance- If your employer has 20 or more employees, then you can hold off on Part B, and will not have to worry about the penalty.

Medicare Supplement Plans

If you do not have employer-based insurance and are looking for extra coverage, then you may want to look into a Medicare Supplement Plan. These plans are sold by private insurance companies and are a secondary form of insurance that helps pay for Medicare Part B bills. Medicare will pay 80% of your Part B bills, leaving you to pay the remaining 20%.

Medicare and other forms of insurance can work together with a coordination of benefits rule. It can be confusing to understand how it all works. EZ.Insure will help make sure you are covered correctly without dealing with any unexpected penalties or bills. Whether it is to help deal with any issues related to Medicare, or to sign up for a Medicare Supplement plan to sustain Part B costs, EZ.Insure has you covered. At EZ.Insure we are trained to be on your side and get you the best plan in your budget. Get an instant quote by typing your zip code in the bar above, or speak with someone now. You can contact one of our highly trained agents by calling 888-753-7207. All of our services are free, because we just want to help you save money. No gimmicks, or obligations.