What Doctors Bill Medicare for Procedures

While Medicare is a great resource for those reaching the age of 65 or those who have certain disabilities or end-stage renal disease, it can still be complicated to use your benefits. 

As you get older, you may be more susceptible to issues, which means more doctor’s visits and procedures or surgeries. Because of more medical needs and increasing treatment costs, you may want to know exactly what billing to Medicare entails and how it can affect what you have to pay out of pocket. 

How Much Do Doctors Charge Medicare for Procedures?

The amount that doctors charge Medicare for procedures depends on a few factors, which is why it may be difficult to pinpoint an exact cost amount. If you’re having a procedure done, a number of things could go wrong, or something minor could happen, which could affect the cost. 

For example, if you’re having surgery and you end up needing more of a certain drug than originally anticipated, that addition will add to the cost. However, that doesn’t mean it's impossible to get an idea of what the cost of a procedure will be.

In addition, doctors are able to charge an amount that is more than what Medicare allows, even if they are a Medicare provider. While a 15% excess charge on a $100 doctor visit isn’t hard to handle, if you’re having a major procedure or surgery that is thousands of dollars and the doctor charges an excess rate, you could be paying thousands more that isn’t covered by Medicare.   

Some states don’t allow healthcare providers to charge an excess fee, while others limit the amount they can charge. That’s why it’s always important to get an idea of what the cost will be, including what will be covered by Medicare and what won’t be, before heading into surgery. You want to avoid being bombarded with charges while you’re in recovery. To get an idea, you can try the options below. 

Ask the provider about the cost of the procedure: Though there are some situations that could occur and make the cost of your treatment fluctuate, if you ask the doctor or healthcare provider, they will be able to tell you how much the procedure will likely cost, in addition to any charges that may be added. 

Generally, providers can tell you how much you will owe: Whether it’s the copayment or the deductible, you can also ask providers how much you’ll owe for the procedure. 

Medicare costs are federally sanctioned: Coverage is decided on a national level, which means that surgeries and procedures are only covered if they are deemed medically necessary on the national level. However, local coverage decisions can also come into play when calculating costs. This means that even if Medicare considers the procedure to be medically necessary, the companies that process claims locally and handle Medicare billing may not agree, resulting in you paying an inflated price. 

Ask about covering your deductible: While Medicare Part A covers expenses related to in-patient hospital stays and surgeries, you’ll pay a deductible during the benefit period. The benefit period is the period of time you are in the hospital or healthcare facility for the procedure. Make sure you know exactly how much you have to pay as a deductible. 

Review post-procedure costs: Ask the surgeon, doctor or other provider what the post-procedure care will be like to get an idea of the cost after you leave the doctor’s office. Will you need crutches or a wheelchair? Will you need to pay someone to take care of you if there are no family members or friends available? What kind of medications are needed after? You could need many things that cost you beyond the procedure itself. 

How to Keep Medical Costs Down

Medical costs can be scary, and while Medicare can help reduce what you pay for care, you can still be overwhelmed with medical bills. Several ways are available to keep medical costs down, most of them having to do with being informed and asking questions. Never be afraid to ask questions — it may end up saving you money. You can also use these additional tips to save more when you need to see a doctor or specialist.   

Verify your Medicare card is valid: This may seem obvious, but it’s possible to let tiny details get away from you, affecting your coverage. Make sure your Medicare card is valid and that you paid the premium for your Medicare Part B and Part A if you have one.  

Ask about “assignment”: “Assignment” means that your healthcare provider agreed to the amount of payment that Medicare approved as the full payment for the services provided. This amount is what you and what Medicare would pay in total. The agreement is a signed contract that the provider is required to adhere to. This typically keeps the provider from charging excess fees, which can up your total cost significantly depending on the service you’re receiving. 

Your healthcare provider is not required to accept assignment so you should ask whether they accept assignment before you receive any treatment. Even if your doctor does not participate in Medicare, they are still able to accept individual assignments on a case-by-case basis. 

Ask about Extra Help for those on fixed incomes: You may be eligible for Extra Help if you have limited income. This means you may be able to get help to pay for medical care costs and prescription medication costs through Extra Help if your income qualifies you to receive it. To apply for Extra Help, fill out Form SSA-1020 and submit it through Social Security. 

Review Alternative Care With Your Doctor

Alternative care consists of services or health treatments not typically offered as traditional Western medicine. There are several different categories of alternative care, but whether insurance covers them depends on the insurance. Medicare Part A and Part B don’t typically cover alternative-care options. Acupuncture and massage therapy are examples of common alternative care choices.  

If you’re interested in receiving alternative treatments, use the following tips to control your costs:

Ask your doctor whether alternative care is covered: Depending on the Medicare plan that you have, services may be covered. 

Review prescription options for alternative care: While prescriptions are covered under Medicare Part D, you can still see what the options are for alternative care. This can be especially useful if you are enrolled in an Original Medicare policy and do not have Part D coverage. 

Ask your doctor whether they can assign alternative care costs: Just as with any other care costs, you can ask whether the doctor accepts assignment for alternative care costs. The process is the same, as they will agree to the amount that was approved to be paid as the full payment. 

Compare Medicare Advantage Plans

A Medicare Advantage plan can offer extra coverage beyond what’s required to be covered under Original Medicare. Benzinga offers insights and reviews on the following Medicare Advantage plan providers. You may want to consider beginning your research for the right policy with a few of the links below. 

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