Medicare makes the first step in the claims process easy: Providers usually submit the claims to Medicare, so you don’t have to do it yourself. But it can be complicated to keep track of the paperwork and to make sure you don’t pay more than you owe when you’re coordinating several types of coverage.
If you’re in traditional Medicare, you’ll get statements from Medicare and your medigap or retiree health insurer. Keep the statements in a file and organize them by the date of the procedure, but don’t pay anything until you get an explanation of benefits, says Sikora. Medicare’s EOB (called a “summary notice”) shows the services providers billed to Medicare over the past three months, what Medicare paid and the amount you owe the provider. “Once you get a bill, pull out the file and look at the EOB,” says Sikora. Match this notice with any bills you receive to make sure that claims for all services have been processed.
If Medicare approves a payment, then medigap should kick in to pay remaining charges (retiree health plans can have different coverage rules; check your plan). Medicare usually sends the claim to your medigap or retiree insurance company directly, but first you have to alert Medicare that you have additional coverage; otherwise, you may get the bill yourself. To get Medicare in the loop, fill out a form when you first sign up for Medicare. You can update the list at www.mymedicare.gov.
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Also pay attention to any “advance beneficiary notice of noncoverage” a provider asks you to sign. This document warns that coverage will likely be denied. It’s possible that the service isn’t covered, but the warning may be the result of a coding mistake. For instance, a diagnostic test (which is covered) might have been coded as a screening (which isn’t covered). Ask questions and identify coding issues up front.
The paperwork is less complicated if you have a Medicare Advantage plan because you aren’t coordinating several policies. But you may have issues if you go out of network or fail to get preauthorization for a procedure. Know the rules for your coverage, and keep notes of authorization, specialist referrals and other relevant information.
If you’re overwhelmed by the claims process, hire a claims specialist by the hour or project to help with the paperwork, fix coding or other errors, and file appeals. To find one, go to www.claims.org. You can also get help—say, with a bill you think should be covered—from your local State Health Insurance Assistance Program. “SHIP counselors are given the direct line to the specialists at Medicare, and we’re able to handle issues over the phone so a problem doesn’t have to go to appeal,” says Shaffer, of Florida SHINE. (You can find a local SHIP counselor at www.shiptacenter.org or by calling 800-633-4227.)
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