It’s no secret that the Medicare world can oftentimes be confusing and complex. With that comes issues with billing – many people across the country will experience claim denials because of an error made during the application or admission process. They may also be surprised by unexpected out-of-pocket costs. By understanding these common Medicare billing issues, Americans can navigate the complexities of their coverage plans more effectively. Here, we’ll list some of the most frequent billing issues and how to avoid them.
Medicare Billing Issues & How to Avoid Them
There are many components involved with healthcare billing and insurance claims, so of course mistakes are bound to happen. If your claim has been rejected or you’re paying for services out-of-pocket without expecting to, here are some common reasons why:
- Incorrect Information
Billing errors can occur when providers submit incorrect information to Medicare. This might include wrong patient details, incorrect procedure codes, or miscommunication about services rendered.
Solution: Always ensure your information is correct and updated if you move, your marital status changes, or more. You can do so by logging into your Medicare account or over the phone.
- Premium Increases
You may face unexpected increases in your monthly premiums, especially if you are on a Medicare Advantage plan. This can be a shock if not anticipated or understood during the enrollment process.
Solution: Make sure you fully understand the Medicare plan you’re enrolling in beforehand. Premiums can increase for reasons such as higher earnings or cost-of-living adjustments.
- Coverage Gaps
People often find themselves surprised by the gaps in coverage, particularly with services such as dental, vision, or hearing care, which are often not included in standard Medicare plans.
Solution: Medicare does not cover services such as dental care, vision care, hearing aids, and long-term care. This can leave people vulnerable to high costs for these essential services that are not covered by the program. To fill these gaps in coverage, some people choose to purchase supplemental insurance, also known as Medigap or Medicare Advantage plans, to help cover costs that are not covered by traditional Medicare.
- Coordination of Benefits
For those who have both Medicare and another insurance plan, coordinating benefits can be confusing. This can lead to billing issues where one insurer does not cover a service, expecting the other to do so.
Solution: To ensure your Medicare coverage is coordinated effectively, you’ll need to fill out a Coordination of Benefits (COB) form to determine which plan is primary and which is secondary for each service. This can help prevent confusion and reduce the risk of billing issues.
- Appealing Denied Claims
When a claim is denied, many people are unsure how to appeal the decision. Understanding the process and knowing what documentation is needed can be critical in resolving these issues.
Solution: Before you start an appeal, ask your provider for information that may help with your claim, contact your plan for more information about what your plan entails to ensure you have all the details straight, and carefully read through how to appeal (which will be included in your plan information). There are specific appealing rules based on the kind of coverage you have. The appeal should be filed within 60 days of the date on the denial notice. If your appeal is denied at the first level, you have the right to continue appealing.
- Further Documentation Requested
An additional documentation request (ADR) may be generated when documentation is necessary to support your Medicare claim. This request is to ensure compliance with Medicare’s coverage, coding, payment and billing policies.
Solution: The ADR will be sent to the provider’s address on file with Medicare, so make sure your information is correct and up to date. The provider will have a certain timeframe in which to respond. Failure to do so may result in claim denial.
Maximize Your Benefits by Avoiding Mistakes
To avoid these common mistakes, it’s important to regularly review your Medicare statements, stay informed about your coverage, and communicate effectively with both your healthcare provider and a Medicare representative. It’s also incredibly beneficial to seek assistance from a Medicare expert who can help you find the best coverage for you, clarify uncertainties, and ensure you’re maximizing your benefits through every stage of life.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.
