Imagine this. You enroll in a Medicare Supplemental Plan where you have no co-pays, deductibles, and can go to any doctor or hospital in the entire country that takes Medicare. Pretty sweet deal - Right?
You go to your dermatologist, pay nothing and then walk away happy. Three weeks later, you get a bill for $500 – the full cost of the visit. What gives?
According to our experience, here are the three most common reasons for a denied claim
1. Your doctor didn’t bill your new insurance.
This is often the most common reason for getting a bill for the full cost of the visit. Despite integrated systems and repeated getting asked for your insurance information every time to show up at the doctor’s office, paperwork can get lost or billing errors can occur.
It can be very likely that your doctor’s office billed your old insurance and was denied. The best way to address this issue is to call back with your Medicare claim number (the number on your red-white-and-blue Medicare card) as well as your Supplemental Plan claim number and ask your doctor to re-bill.
Next time you visit the doctor, see if the front office can make a copy of your Medicare and your Supplemental insurance card and include it in your patient file
2. Your doctor doesn’t take Medicare.
More and more doctors are leaving the insurance system because of low reimbursements and compliance overhead. Just because you can go to any doctor or hospital in the country that takes Medicare doesn’t mean that your doctor is guaranteed to take Medicare (I know, it sounds obvious now). It’s best to call the doctor’s office to confirm. Unfortunately, if Medicare is your only option and your doctor does not accept Medicare, you may have to end up paying cash or finding a new doctor.
3. Your procedure wasn’t considered medically necessary.
Medicare has a comprehensive list of covered items. Typically, if Medicare considers a procedure medically necessary, it will be covered.
Almost all cosmetic procedures are not covered. So if you’ve been waiting for your supplemental plan to cover Botox, you may be out of luck.
If you’re unsure if a procedure is considered cosmetic or whether Medicare will cover it, it’s best to double check with your doctor’s billing office before you undergo the procedure.
Bonus: you don’t have a Medicare Supplemental Plan
Many individuals confuse Supplemental plans with Advantage plans. Advantage plans are NOT Supplemental plans even though they may offer additional benefits to Medicare otherwise not included. An Advantage plan often has a lower monthly premium in exchange for restrictions such as a narrow network and co-pays/co-insurances.
If you are in an Advantage plan, your preferred doctors may not be in the network. Some Advantage plans will not cover out of network doctors unless it’s an emergency. In this case, you’ll have to double check with your agent or your insurance company to make sure that your preferred doctors and hospitals are included in the network.