Alyssa Lane
Medicare is a federal government-sponsored program that provides health insurance for American citizens aged 65 and over. Medicare Part B (Medical Insurance) covers medically necessary doctor services, including outpatient services and some inpatient hospital doctor services. If you have Original Medicare, the law requires your doctor to file Medicare claims for covered services and supplies. If your doctor does not accept Medicare as full payment, you may have to pay the full amount at the time of service, and they should submit a claim to Medicare for any Medicare-covered services. You can also submit your own claim if your doctor has not filed one on your behalf.
| Characteristics | Values |
|---|---|
| Medicare filing requirements for doctors | Doctors who accept Medicare are required by law to file Medicare claims for covered services and supplies received by the patient. |
| Medicare drug plans | If a patient has a separate Medicare drug plan (Part D), the pharmacy files a claim directly with the patient's plan. |
| Medicare health plans | If a patient has a Medicare Advantage (Part C) plan, in-network doctors will usually submit a claim directly to the patient's plan. |
| Medicare claim forms | Patients can download and fill out a "Patient Request for Medical Payment" form (CMS-1490S). This form is also available in Spanish. |
| Supporting documents | Patients may need to submit supporting documents such as notes from their doctor along with the claim form and itemized bill. |
| Claim submission deadline | Medicare claims must be filed within 12 months (or 1 full calendar year) of the date the services were provided. If a claim is not filed within this time frame, Medicare will not pay its share. |
| Claim status check | Patients can check the status of their claim by reviewing the "Medicare Summary Notice" (MSN) received in the mail, logging into their secure Medicare account, or checking their plan's claims statements. |
| Non-participating providers | Doctors who are non-participating providers have not signed an agreement to accept assignment for all Medicare-covered services but may choose to accept assignment for individual patients. |
| Opt-out providers | Opt-out providers do not accept any Medicare reimbursement, and patients are responsible for paying the full bill out-of-pocket. Medicare does not pay for any portion of the bills from these providers, except in emergencies. |
| Medicare Advantage Plan networks | Physicians in Medicare Advantage Plan networks have agreed to accept the network's fees. |
| State Health Insurance Assistance Program (SHIP) | Patients can contact their State Health Insurance Assistance Program (SHIP) for help before signing a private contract with a doctor or healthcare provider. SHIP provides free local health insurance counseling to people with Medicare. |
| Medicare-approved amounts | If a doctor accepts the Medicare-approved amount as full payment for a covered service, it is called "accepting assignment." Most doctors accept assignment, but patients should always check. This can result in lower out-of-pocket costs for the patient. |
| Non-accepting providers | Doctors who do not accept assignment may charge more than the Medicare-approved amount, but in many cases, the charge cannot be more than 15% above the Medicare-approved amount for non-participating providers. |
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What You'll Learn
Medicare claims must be filed within 12 months of service
Medicare claims must be filed within 12 months of the service date. This is a strict one-year deadline, and Medicare won't pay its share of the claim if it's filed after this date. For example, if you see your doctor on March 22, 2019, your doctor must have filed the Medicare claim for that visit by March 22, 2020.
There are a few exceptions to the 12-month filing deadline, but they are limited and specific. You can find out more about these exceptions in the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, Section 70.
If you have Original Medicare, your doctor or supplier is required to file Medicare claims for covered services and supplies. If your doctor hasn't filed a claim on your behalf, you should contact them and ask them to do so. If they still don't file a claim, you should call 1-800-MEDICARE to ask for the exact time limit for filing a claim for the service you received. If it's close to the end of the time limit, you should file the claim yourself. You can download and fill out a form called the Patient Request for Medical Payment form (CMS-1490S). You will need to submit the completed form, along with an itemized bill from your doctor and any supporting documents, to the address for your state, which is listed on the Medicare Administrative Contractor Address Table within the claim form.
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Doctors must file claims for covered services
In most cases, doctors' offices will submit claims directly to your insurance company. They will send a bill for any charges that you did not pay during your visit or submit a claim for the services provided. The insurance company will then process the claim, checking for completeness, accuracy, and whether the service is covered under your plan. If the service is covered, the insurance company will pay the doctor directly.
If your doctor has not filed a claim on your behalf, you should contact them and ask them to do so. If they continue to not file a claim, you may need to submit your own claim. This process may involve downloading and filling out a form, such as the Patient Request for Medical Payment form (CMS-1490S) for Medicare claims. You will also need to submit supporting documents, such as an itemized bill from your doctor and any relevant medical records.
It is important to regularly review your health insurance claims to keep track of your medical expenses and ensure you are not charged unexpectedly. Additionally, if you have Medicare, it is worth noting that Medicare typically pays doctors only 80% of what private health insurance pays. As a result, you may need to cover additional expenses through a Medigap insurance policy or Medicare Supplement Insurance.
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Medicare Part B covers medically necessary doctor services
If you have Original Medicare, your doctor is required by law to file Medicare claims for covered services and supplies. However, if your doctor has not filed a claim on your behalf, you should contact them and ask them to do so. If they still do not file a claim, you may need to submit your own claim. You can call 1-800-MEDICARE for help with your claim.
Medicare claims must be filed within 12 months of the date the services were provided. If a claim is not filed within this time frame, Medicare will not pay its share. It is important to check the "Medicare Summary Notice" (MSN) or your secure Medicare account to ensure that claims are being filed in a timely manner.
It is worth noting that Medicare typically pays doctors only 80% of what private health insurance pays, and you may need to cover the remaining 20% of the Medicare-approved amount for most services. However, for certain preventive services, you may pay nothing if your doctor accepts assignment.
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Doctors who don't accept Medicare can still see patients
Medicare is a federal government-sponsored program that provides health insurance for American citizens aged 65 and over. Doctors who don't accept Medicare can still see patients, but they are known as "opt-out" providers. Opt-out doctors accept no Medicare reimbursement and expect patients to pay their full fee. Medicare won't pay for any portion of the bills from these doctors, so patients are responsible for paying the total bill out of pocket. Opt-out doctors are required to reveal the cost of their services upfront and have patients sign a private contract agreeing to the opt-out arrangement.
If you cannot afford to stick with an opt-out doctor, you can ask them to recommend another doctor in your area who does accept Medicare. You can also find a list of physicians and healthcare providers who accept Medicare in the Physician Compare directory on Medicare's website.
Another option is to see a "non-participating" doctor. These doctors haven't signed an agreement to accept Medicare reimbursement for all covered services, but they can still choose to accept reimbursement for individual patients. Non-participating doctors can charge up to 15% more than the official Medicare reimbursement amount, so patients may have to pay the difference between the fees and the Medicare reimbursement.
If your doctor is not participating in Medicare, they should submit a claim to Medicare for any Medicare-covered services they provide. If they refuse to submit a claim, you can submit your own claim to Medicare using Form CMS-1490S.
It's important to note that the number of doctors who don't accept Medicare is relatively small, and most beneficiaries can see the doctors they want. However, there may be pockets of the country, especially in wealthier urban areas, where a higher percentage of doctors no longer accept any insurance.
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Medicare Advantage Plan networks are an alternative to individual doctors
Medicare Advantage Plans, also known as Part C, are an alternative to Original Medicare and are offered by private insurance companies. They cover Part A and Part B, and most include Part D (prescription drugs). Medicare Advantage Plans have a network of contracted doctors and hospitals that coordinate to meet individual healthcare needs. These plans are typically either HMOs or PPOs. HMOs generally require members to use in-network doctors and hospitals, while PPOs allow members to go out-of-network for a higher cost.
In contrast, traditional Medicare allows beneficiaries to see any doctor or visit any hospital that accepts Medicare anywhere in the United States. This includes the vast majority of doctors and virtually all hospitals. Medicare Advantage Plans, on the other hand, have more limited provider networks, and a 2017 analysis found that they included fewer than half (46%) of all Medicare physicians in a given county, on average.
Medicare Advantage Plans also differ from traditional Medicare in that they often include extra benefits, such as routine vision, hearing, and dental services. They also have an annual cap on out-of-pocket expenses, which is $8,850 for in-network services in 2024. However, unexpected costs may arise if a doctor or specialist outside of the plan's network is visited. Additionally, Medicare Advantage Plans may limit hospital stays and make treatment decisions that differ from the treating doctor.
When choosing between traditional Medicare and a Medicare Advantage Plan, it is important to carefully compare the options and ensure that the desired doctors and providers are in the plan's network. It is also crucial to consider future healthcare needs and whether the prescribed treatments and care would be adequately covered.
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Frequently asked questions
Medicare is a federal government-sponsored program that provides health insurance for American citizens ages 65 and over.
If your doctor is a non-participating provider, they haven't signed an agreement to accept Medicare reimbursement rates for all Medicare-covered services, but they can still choose to accept these rates for individual patients. If your doctor is an opt-out provider, they will not accept any Medicare reimbursement and you will be responsible for paying the total bill out of pocket.
If you have Original Medicare, you'll need to mail your claim form, itemized bill, and supporting documents to the address for your state. If you have a separate Medicare drug plan (Part D), the pharmacy will file a claim directly with your plan. If you have a Medicare Advantage (Part C) plan, in-network doctors will usually submit a claim directly to your plan.
Medicare claims must be filed no later than 12 months after the date the services were provided. If a claim isn't filed within this time, Medicare won't pay its share.
Contact your doctor and ask them to file a claim for the service or supply you received. If they haven't filed your claim, call 1-800-MEDICARE. If it's close to the deadline and your doctor still hasn't filed a claim, you should file the claim yourself.
