Medicare claim approved amount

[Russell Rewis]

A provider who accepts assignment and is a member has billed Medicare $8000.00 and Medicare approved that amount but only paid provider $1000.00. The Medicare web site states that Medicare pays the approved amount. I understand the 80/20. Will someone please explain? I called Medicare twice and could not get the answer.
Thanks for any info,
Russell

 

[Kaila]

I think it's that the service provided for the $8,ooo charge the provider says it costs, is an accepted service.
So the 80/20 will apply, after the provider adjusts the price.

And therefore, Medicare pays 80%, according to what the Medicare fee scale shows for that service, (far less than the providers original price quoted)

The Provider makes an "adjustment" which is a credit sort-of, and is subtracted from the whole of your original bill. That is what they agreed to do, when they "accepted assignment."

Then it comes out to your paying the 20% (of the Medicare-approved amount.)

The 80/20 applies because it's a covered service.
but the provider price is reduced, because the provider accepts assignment.

The best thing to do, whenever you are in doubt, or in general, is to wait until you get, in the paper mail:
an explanation from Medicare itself, which will show exactly how much that Medicare was billed by each one of your providers, and whether Medicare approves the service, and how much Medicare paid if it did approve the service,
and then, that same paper, says:
What that provider is allowed to bill you.
(That is the max you should pay your provider. Not more.)

This paper statement from Medicare, usually gets to you, in your mail, within 2 weeks or so, from when they received the provider's bill, so it is not long to wait, and a Provider should be willing to wait till you see that, before you pay them your part of the balance.
The provider will already have received Medicare's notice, and will have received payment from Medicare,
unless A) it is not a covered service, or B) you haven't met your yearly deductible yet.

If A; then you might have to pay it to the Provider, but you might not, if you were not given info that it likely would not be a covered service by Medicare.

If B; then, then your amount to pay would still be reduced, but you will have to pay the deductible total to all your providers, before Medicare actually pays their 80%.
Be sure to let the Provider bill Medicare, for everything, so that the charges WILL count toward your deductible.
This occurs every year in January.
I hope this helps.
I am not an expert, but have some experience with this topic.

 

[Wigglestein]

I recently used the "estimate" feature on my patient portal at Mayo. You tell them what you are having done and they give you an estimate based on you insurance. Unfortunately, it looks like they will only process it for one insurance. So having a private insurance as my primary I still have to call Medicare to see what they will pay as my secondary. I think the estimates are now required by law.

 

[Myrtle]

I recently used the "estimate" feature on my patient portal at Mayo. You tell them what you are having done and they give you an estimate based on you insurance. Unfortunately, it looks like they will only process it for one insurance. So having a private insurance as my primary I still have to call Medicare to see what they will pay as my secondary. I think the estimates are now required by law.

Wigglestein, your private insurance is your primary? I didn't know that could be done.

Kaila, that is a good explanation. I'm always a bit at sea with my Medicare.

Welcome to the forum, Russell. I just now noticed that you are new. I hope you will join in other threads and like it here.

 

[Wigglestein]

Wigglestein, your private insurance is your primary? I didn't know that could be done.

My husband works fulltime so we have really good private insurance. Under Obamacare, the law was changed to require that if you could get private insurance thru your employer that that automatically became your primary. I still pay the same Medicare premiums but get little or no payments on my bills.

 

[Russell Rewis]

I think it's that the service provided for the $8,ooo charge the provider says it costs, is an accepted service.
So the 80/20 will apply, after the provider adjusts the price.

And therefore, Medicare pays 80%, according to what the Medicare fee scale shows for that service, (far less than the providers original price quoted)

The Provider makes an "adjustment" which is a credit sort-of, and is subtracted from the whole of your original bill. That is what they agreed to do, when they "accepted assignment."

Then it comes out to your paying the 20% (of the Medicare-approved amount.)

The 80/20 applies because it's a covered service.
but the provider price is reduced, because the provider accepts assignment.

The best thing to do, whenever you are in doubt, or in general, is to wait until you get, in the paper mail:
an explanation from Medicare itself, which will show exactly how much that Medicare was billed by each one of your providers, and whether Medicare approves the service, and how much Medicare paid if it did approve the service,
and then, that same paper, says:
What that provider is allowed to bill you.
(That is the max you should pay your provider. Not more.)

This paper statement from Medicare, usually gets to you, in your mail, within 2 weeks or so, from when they received the provider's bill, so it is not long to wait, and a Provider should be willing to wait till you see that, before you pay them your part of the balance.
The provider will already have received Medicare's notice, and will have received payment from Medicare,
unless A) it is not a covered service, or B) you haven't met your yearly deductible yet.

If A; then you might have to pay it to the Provider, but you might not, if you were not given info that it likely would not be a covered service by Medicare.

If B; then, then your amount to pay would still be reduced, but you will have to pay the deductible total to all your providers, before Medicare actually pays their 80%.
Be sure to let the Provider bill Medicare, for everything, so that the charges WILL count toward your deductible.
This occurs every year in January.
I hope this helps.
I am not an expert, but have some experience with this topic.

Kaila, thank you very much for your explanation. I was confused because in the past the approved amount has always been less than the provider billed amount. I have never understood why a provider would accept such a cut in payment for most all charges, in this case $7,000.00!
This service was preformed on January 17, 2023. I get my eMSN’s off of the web site. They are posted monthly but the January MSN has not shown up yet but the information of the claim is posted.
Yes, this is my first day on this forum and I already see that I’m glad I happened upon it. Thanks for the welcome and all the valuable information you have provided.
Russell

 

[Russell Rewis]

Wigglestein, your private insurance is your primary? I didn't know that could be done.

Kaila, that is a good explanation. I'm always a bit at sea with my Medicare.

Welcome to the forum, Russell. I just now noticed that you are new. I hope you will join in other threads and like it here.

Myrtle, thanks for the welcome. I see this forum as being very helpful.
Russell

 

[jujube]

That $8000 that they bill Medicare or any insurance company is some pie-in-the-sky number they've pulled out of a hat, knowing full well that they'll never get paid that much by anybody. So, they might as well start high before the bargaining starts.

Medicare or private insurance or Medicaid won't pay it because they've pre-negotiated what they will pay when the doctor signs up with them. Private patients without insurance probably will never pay it because they'll either make a deal somewhere down the line to pay a lesser amount or will just declare bankruptcy and pay nothing. The very, very, very few individuals who will end up paying the $7000 are a bonus.

 

[Kaila]

Kaila, thank you very much for your explanation. I was confused because in the past the approved amount has always been less than the provider billed amount. I have never understood why a provider would accept such a cut in payment for most all charges, in this case $7,000.00!
This service was preformed on January 17, 2023. I get my eMSN’s off of the web site. They are posted monthly but the January MSN has not shown up yet but the information of the claim is posted.
Yes, this is my first day on this forum and I already see that I’m glad I happened upon it. Thanks for the welcome and all the valuable information you have provided.
Russell

You are welcome, in both ways.
As in Thanks, and the response, You're welcome!
and as in, Welcome to our SF forum!

Why do the Providers settle for so much less than their price?

The Provider will get their price, or more of it, from other patients and from other insurance coverages, which is why they set the high prices;
while they know that Medicare uses Medicare's own price amounts for each service.
The Provider benefits from seeing Medicare patients.
They would not be allowed to outright, charge different prices for the same service to different patients, so this is how they legally do it.
They set their price, while they know they will adjust it, according to Medicare's rules.

I'm glad this was helpful. I hope to see you interact on other threads you might find of interest.

 

[Kaila]

I just had another possibly clarifying thought, to add.

When you receive an Itemized bill from your Provider, it will start with that large figure, and in addition, will then show what Medicare paid, and will show the adjustment as another credit; until it ends up with your actual balance.

 

[Kaila]

I like that Medicare also indicates with footnotes, for you to see: the reason WHY they paid whatever they paid, or more importantly, why they did not pay whatever they did not.

Reasons they did not pay, would include: if it, or any portion of it, must count toward your yearly deductible, or if it is a duplicate of a charge already decided upon previously, or if it is not a covered service. (Or if the Provider's office waited more than a year to bill them, which is rare, but does happen)

 

[Colleen]

In August, 2021 my hubby had a total knee replacement. The hospital billed for almost $111,000, but Medicare (Humana) only paid $12,000. We paid $289.00. The doctor was a separate charge.

 

[Teacher Terry]

Hopefully you have a supplement that will pick up the other 20%. I never pay anything other than the 233 deductible.

 

[Russell Rewis]

In August, 2021 my hubby had a total knee replacement. The hospital billed for almost $111,000, but Medicare (Humana) only paid $12,000. We paid $289.00. The doctor was a separate charge.

Wow. Do you remember what the Medicare approved amount was? $289.00 is a long way from 20%. Must have been a lot of complex rules and guidelines involved.
Russell

 

[Russell Rewis]

Hopefully you have a supplement that will pick up the other 20%. I never pay anything other than the 233 deductible.

Yes, I have a supplemental policy but I’ve been trying to decide if I want to keep it. I’ve ran the figures for the last 5 years. I’ve had 3 surgeries during that time frame and only 1of those 5 years did the supplement pay out more than I paid in premiums and even then it was less than $300.00.
Russell

 

[Kaila]

While deciding, you might want to also consider whether your supplemental plan includes meds or not.

If yes, then it may be a bit more worth wile to keep it.
Especially if it covers a comprehensive list of drugs, or costly ones that you or wife are particularly likely to need.

If your supplemental plan does not cover any meds, or if you are going to drop a supplemental plan which does;

then you may want to pick up a stand-alone Medicare Part D.
The Part D plans vary widely in price, but for many people, the more expensive ones do not help any more than the cheaper ones. Meaning that choosing a Part D plan with very low premiums is sufficient for many people, in my opinion.

I agree with your comment, Russell, that for some of us, I do not see the dollar value of paying the significant monthly premiums for a Medigap policy, as the supplemental plans are now called. As you point out, it seems to me as well, that they very rarely pay for themselves.
The premium payments go out every month and are significant.
I haven't found the 20% to be enormous, and the supplement plans have exclusions as all plans do.

 

[Teacher Terry]

As of now I have paid more for the supplement than I have collected. But you can’t predict when you will have enormous bills and then you will be glad you have it. It’s why it’s called insurance. You are insuring for an event that may never happen.