My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?
Answered by 9 licensed agents
Suppose you're under Medicare Part A and Part B with a Medicare supplemental insurance, and the physician sees a need for a diagnosis due to your health circumstances. In that case, the procedure should be covered, less any amounts for Medicare Part B premium or deductibles, and this is based on the type of supplemental plan you have. If you're on Medicare Part A and B with a Medicare Part C - Advantage plan, then your coverage could only be determined with the prior approval procedure through the insurance carrier of your Advantage plan. Most likely, there will be additional deductibles, co-pays, or out-of-network charges under these plans.
You can contact your insurance company and ask. Get the persons name you talk to, phone, badge number if it applies and the date and time of your call. You can go onto Medicare.gov and search there too. You can contact the billing department of your doctors office and ask. They bill insurance and know what they pay on or don’t. Hope that helps.
The only healthcare procedures that are NOT covered are those of an experimental nature. However, once the CDC checks out these types of treatments, as long as it meets the quirky Federal guidelines, it may be declared to be covered. Be advised that there are over 60,000 treatments that are currently covered by Medicare. Your doctor was being honest with you and the odds are that most of the "uncovered" treatments are those recommended by a chiropractor since they can (via trial-and-error) attempt to develop a procedure that she/he successfully worked with "some" of their patients. Your best double-check is always to call 1-800-MEDICARE and the reps should be able to sanction a procedure unless it is brand new and has yet to be tested.
To ensure your procedure is covered by Medicare before incurring unexpected costs, you should first ask your doctor or the facility if they accept Medicare and if they will accept assignment. You can also verify coverage on the Medicare.gov website . If coverage is uncertain, inquire about potential out-of-pocket costs and ask if the provider will file a claim with Medicare, even if they anticipate a denial.
Contact the carrier you have for your Medical coverage, or refer to your evidence of coverage on your policy. If all you have is original Medicare, you may call 1-800-Medicare for more information.
Original Medicare will not pay for certain things, like physical exams, cosmetic surgery, dental, vision, or hearing aids. Original Medicare and Medicare Advantage plans will both require prior authorizations before any major procedures are done. These requests for prior authorizations are the responsibility of the doctor and or hospital to obtain before medical procedures start.
Speak with the billing office at your doctor's office. As an agent, I'm always happy to assist you with speaking directly with your insurance carrier further.
