Are You Being Overcharged for Medicaid and Medicare?

Do you, or perhaps your parents, receive Medicare or Medicaid benefits? If so, your doctors could be billing you improperly. Many times this isn’t due to nefarious practices or fraud—although this certainly does happen—but simply because providers don’t understand the laws or procedures, and their mistakes end up costing you money.

Educating yourself on what your healthcare provider can and can’t do could end up saving you a lot of money and hassle.

Why would a doctor send you bills if you don’t owe them money?

You might wonder why or how you’d be billed improperly or by mistake. Following are a few pieces of information you should keep in mind and a couple common scenarios of billing errors.

First, remember that billing rules are different depending on whether you use Medicare (for people 65 or older), or Medicaid (for people of any age who have limited resources due to disability or other reasons). With Medicare, full coverage isn’t guaranteed—you may be responsible for some charges, but you should still look at any bills from your provider very carefully. With Medicaid, however, you should be wary of any bill you receive from your provider.

Here are three common examples of why you might get a Medicaid or Medicare-related bill from your provider—coverage issues, administrative errors, and balance billing.

1. Your healthcare provider made an administrative error. This is why you should always read your bills instead of paying them without question. Sometimes you might receive a bill in error because perhaps your provider filed the claim late, or didn’t include the required documentation from your visit. In cases like these, you shouldn’t be responsible for the bill and can file an appeal to clear up the mistake.
2. Medicaid doesn’t cover the service or doctor. There may be a coverage issue if Medicaid doesn’t cover the service you were provided. However, you may dispute this if you were not notified that the services weren’t covered. Healthcare providers are required to tell you that a service isn’t covered before performing and charging you for that service. You may also run into a coverage issue if Medicaid has dropped your doctor and didn’t notify you. Again, this may be able to be negotiated.
3. Balance billing. Balance billing is when providers bill their patients for the difference between the reduced rate Medicare/Medicaid pays them and their “retail” price for services. Here’s an example. If an office visit retails for $200, that’s how much an uninsured patient would pay. The price of that visit for Medicare patients is capped at $100, meaning the provider writes off the other $100.

If Medicare covers $80 of the remaining balance, that leaves $20 that you’re responsible for. However, your doctor might bill you $120 instead, so they can collect the full price for their service. This is prohibited under Medicare and providers cannot balance bill their Medicare patients!

You should receive an explanation of benefits after your provider submits a claim. If you receive a bill before your explanation of benefits, you should question that bill.

The Phoenix injury attorneys at Plattner Verderame, P.C. have your best interests in mind when it comes to the health of you and your loved ones. We protect your rights when healthcare providers try to take advantage of you. Get in touch with us today by calling 602-266-2002 or filling out our contact form.