Merritt Personal Lines Manual: Chapter 6 Choosing a Doctor
About half of the doctors in the country will accept the amounts paid by Medicare as payment in full. This is referred to as accepting the Medicare assignment. As an example, if a pathologist or radiologist who performs services on an inpatient basis will accept a Medicare assignment, Medicare will pay 100 percent of reasonable charges. Medicare will also pay the cost of a Medicare-required second opinion for surgery with no 20 percent copayment. Medicare will also pay for services of other specialists on the same 80 percent of reasonable charges basis.
Doctors who do not accept Medicare assignments are prohibited by law from charging more than 140 percent of the Medicare prevailing charge for office and hospital visits. For other services, such as surgery, the limit is 125 percent.
In the past, some doctors have tried to circumvent these limiting charges by requiring patients to contract to pay full charges. The Health Care Financing Administration has cautioned that these contracts are not valid.
Doctors, suppliers and other providers must submit claims for covered Part B services directly to Medicare, regardless of whether they are a participating or a nonparticipating provider. Some doctors ask patients to waive the right to have doctors submit Medicare claims and obligate the patient to pay privately for Medicare-covered services. These waivers are also invalid, according to the HCFA and could subject physicians to civil penalties.
If your doctor has not accepted your Medicare assignment, he will send the bill for Part A services directly to you. In turn, you fill out a Medicare claim form and attach any itemized bills from your doctor including date of treatment, place of treatment, description of treatment, doctor's name and charge for service. The documents are then sent to the Medicare adminstrator in your area. Upon receiving the claim, the administrator will send an Explanation of Medicare Benefits, showing which services are covered and the amounts approved for each service.
If your Medicare claims are denied, you are probably going to want to appeal your claim.
Within six months of receiving the Explanation of Medicare Benefits notice, you must file a written request for review. The administrator will check for miscalculations or other clerical errors. If the administrator declines to make a change, an appeal can be made to the Social Security office (but only if the amount disputed is $100 or more).
You must appear in person to attend a hearing and present evidence, such as a doctor's letter, to support your point. A written notice of the decision will be sent to you after the hearing.
