Doctor no longer accepts Medicare… How do I file a medical claim?

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Hi Toni:

I recently enrolled in Medicare. This week, I went to see my primary care doctor and his office manager informed me that they are no longer accepting Medicare. Instead, I will have to pay the complete bill up front and be reimbursed by Medicare. His office is small, and the doctor will be retiring soon. I will need to find a new doctor.

Toni, can you please explain what I need to do to submit the doctor bill to be reimbursed by Medicare?  

--- Beth 

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Hello, Beth:

I am hearing about this problem from the Medicare clients, who come to the Toni Says office for a consultation, saying that a few of the primary care/medical providers are retiring. The office paperwork, whether it is for Medicare-age patients or those under 65 medical claims, is very overwhelming. These offices do not accept Medicare, as your doctor is doing, and will not bill Medicare. The medical provider’s office wants their patients to submit the claim to Medicare and wait to be reimbursed.

Beth, did the doctor’s office charge you full rates and have you pay when leaving the appointment? And then you had to file with Medicare and be reimbursed from Medicare what Medicare pays rather than what doctor charged you? I have not heard of this problem with larger medical offices, especially those that are part of a hospital system.

My advice to Toni Says clients who are new to Medicare is to begin searching for medical providers that accept Medicare, especially for those on Medicare who have a serious health issue.

Below are a few Medicare tips when filing a medical claim that can help you:

• Before you set the appointment for your medical visit, ask the doctor’s office if they are still accepting Medicare. Most important, if this is a new doctor’s office, ask whether that office is accepting “new Medicare patients” and whether that office will bill Medicare directly.

If the doctor’s office says “no” to the second question, Beth, you need to decide:                                             

1. Do you want to pay out of pocket and be reimbursed only what Medicare pays? Remember, doctors know they are not paid their asking rates. Medicare is not the only insurance plan that discounts the doctor’s bills. Group and individual health insurance plans with network providers also discount the doctor’s bills.

Or…

1. Do you want to look for a doctor or specialist who accepts Medicare assignment and bills Medicare directly? (Again, you should verify that the office is accepting new Medicare patients.) Ask your current primary care doctor for more than one doctor or provider that he/she recommends for your specific medical situation.

If your doctor does not accept Medicare, it is not hard to file a claim. You may have to pay the complete bill and send the claim to Medicare. Make a copy of your medical bill to send to Medicare, along with any information about your medical claim.

Visit Medicare.gov and in the search bar type “filing a claim.” The information provided will explain how to submit a claim and to download the claim form CMS-1490S, “Patient’s Request for Medical Payment”. The CMS-1490S form has instructions about submitting the form with an itemized bill and supporting documents. The form also lists by state where you need to send everything. Beth, if you need help filing a claim call Medicare at 800-MEDICARE (633-4227) and ask the Medicare agent for help filing the claim. Medicare will be happy to help.

Need additional help understanding Medicare? Toni’s new course, a downloadable video series called the “Confused about Medicare Workshop,” and the “Medicare Survival Guide Advanced” edition are available at www.tonisays.com.

For answers to your Medicare questions and retiring issues, call the Toni Says Medicare team at 832-519-8664 or email [email protected]. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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