It can be stressful when a doctor or other healthcare provider refuses to bill Medicare for the care you received. Fortunately, there are steps you can take to address the problem if it comes up, no matter what the reason. In some cases, you may just need to remind your provider to file the Medicare claim, while in others, you may have to learn how to file a Medicare claim yourself.
Let’s look at three potential scenarios and how you should proceed in each one. (But bear in mind that these scenarios apply only to patients with Original Medicare. If you have Medicare Advantage, you’ll need to work with your specific plan provider to determine coverage.)
1) Your provider gives you an Advance Beneficiary Notice of Noncoverage (ABN).
What it means: Your provider may ask you to sign an ABN if she plans to provide care that she believes Medicare won’t cover. If you sign the ABN, you’re agreeing to pay the provider for these services if Medicare doesn’t.
What you can do: Before signing, find out why your provider doesn’t think Medicare will cover the service. Does she consider the service medically necessary? If not, you might reconsider whether to get it. If you do feel the service is medically necessary and want to go ahead with it, ask your provider if she’ll help you appeal if Medicare denies coverage. (Here are some tips for communicating with healthcare providers to help you start the conversation.)
If Medicare denies your claim, you can file an appeal, with or without the help of your provider. For instructions, check out Section 8 of the Medicare and You Handbook 2021.
2) Your provider refuses to bill Medicare without explanation and is demanding you pay out-of-pocket.
What it means: It could be that the service provided is never covered by Medicare—as is the case for cosmetic surgery to improve your appearance, for example. In that situation, the provider isn’t required to give you an ABN to sign (although some still do). It could also be that your provider made a mistake or even that she’s committing fraud.
What you can do: Ask your provider to file a claim. If she replies that she doesn’t think the service will be covered, ask her to file it anyway so that you can appeal, if necessary. Remind her that as a Medicare-enrolled provider, she is legally required to file claims for covered services. Keep in mind that there’s a time limit for claims: The claim must be filed within 12 months of the service. If time is running out, there are two things you can do: Report the provider for fraud and file a Medicare claim yourself.
How to file for fraud: You can get help making a fraud report from Senior Medicare Patrol. You can call 1-800-MEDICARE (1-800-633-4227) and/or the Inspector General’s fraud hotline at 1-800–HHS–TIPS (1-800-447-8477).
How to file a Medicare claim on your own: Follow the instructions on Medicare’s website or call 1-800-MEDICARE (1-800-633-4227) for help. The main step is sending in a Patient’s Request for Medical Payment form, an itemized bill, a letter of explanation, and any other supporting documents. The instructions on the request form explain where to mail the documents.
Even if Medicare ultimately denies your claim, if it turns out that your provider was required to warn you about potential non-coverage but didn’t, you may be entitled to a refund. For instance, if a service is normally covered but wasn’t medically necessary in your case, your provider should have warned you about that.
3) Your provider has opted out of Medicare.
What this means: Your provider never enrolled as a Medicare provider or disenrolled. She doesn’t bill Medicare for her services.
You can verify whether your provider has opted out by searching for her name on the Medicare website. However, you should already have been aware that your provider has opted out before you receive services because providers are required to sign a private contract with you, spelling this out. They’re also required to let you know if your treatment would be covered by a Medicare-enrolled provider.
What you can do: If you signed a private contract with the provider, you can’t get reimbursement from Medicare. If this is the case, don’t file a claim. In the future, verify beforehand that the provider bills Medicare.
However, if you didn’t sign a private contract, you can appeal to Medicare to ask for coverage. Also, if you need emergency treatment, you can’t be asked to sign a private contract in order to get it. Medicare covers emergency treatment regardless of the provider’s status.
Only a health insurance broker licensed to sell Medicare plans can help you compare your plan options from various insurance companies. When you’re ready, we recommend you discuss your needs with a YourMedicare.com Licensed Sales Agent.
Return to: Medicare In-depth
Clicking third-party links will open a new tab and will take you away from YourMedicare.com. YourMedicare.com, LLC does not control the linked sites’ content or link.