Does Medicare Part A Cover Inpatient Surgeon?
While Medicare Part A primarily covers hospital inpatient services, it does not directly cover the surgeon’s fees. The surgeon’s services are typically billed under Medicare Part B.
Understanding Medicare Part A and Surgical Procedures
Medicare can be confusing, especially when dealing with complex procedures like surgery. It’s essential to understand how each part of Medicare works to determine what is covered and what costs you might be responsible for. This article will break down how Medicare Part A relates to surgical care received during a hospital stay.
What Medicare Part A Covers
Medicare Part A, also known as hospital insurance, helps cover your costs when you’re admitted to a hospital, skilled nursing facility (SNF), hospice, or for some home health care. It generally covers:
- A semi-private room
- Meals
- General nursing services
- Hospital tests and procedures
- Medical appliances and equipment used in the hospital
- Rehabilitation services
Critically, Medicare Part A does not directly pay your surgeon’s bill. Instead, it pays for the facility costs associated with your surgery while you are an inpatient.
The Role of Medicare Part B
The fees for your surgeon, anesthesiologist, and other physicians involved in your care are typically covered by Medicare Part B, which is medical insurance. This part of Medicare helps pay for:
- Doctor’s services
- Outpatient care
- Preventive services
- Durable medical equipment
Therefore, while Medicare Part A covers the facility fees associated with your inpatient surgery, Medicare Part B covers the professional fees charged by your surgeon.
Navigating Surgical Billing: Part A vs. Part B
The billing process can be segmented by each part. Consider this example:
| Service Category | Medicare Part Coverage | Example Costs (Vary Widely) |
|---|---|---|
| Hospital Room & Board | Part A | $5,000 |
| Surgeon’s Fee | Part B | $3,000 |
| Anesthesiologist’s Fee | Part B | $1,000 |
| Hospital Tests | Part A | $1,500 |
In this scenario, Part A would cover the $5,000 for room & board and $1,500 for hospital tests (subject to your deductible), while Part B would cover the surgeon’s and anesthesiologist’s fees (also subject to deductibles, coinsurance and if your doctor accepts assignment). Understanding this division is crucial for managing your healthcare expenses.
Medicare Advantage Plans (Part C)
Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare. These plans must cover at least as much as Original Medicare (Part A and Part B) and often include additional benefits like vision, dental, and hearing coverage. The way surgery is covered will depend on the specifics of your plan. It’s essential to check with your plan provider to understand your coverage, copays, and deductibles for inpatient surgical procedures. Many Medicare Advantage plans follow similar Part A and Part B splits, but network restrictions and prior authorization requirements can significantly impact your out-of-pocket costs. Always confirm with your plan before scheduling surgery.
Common Mistakes and How to Avoid Them
A frequent mistake is assuming that Medicare Part A covers all costs associated with an inpatient surgery. This often leads to unexpected bills from the surgeon’s office. To avoid this:
- Always confirm with your surgeon that they accept Medicare assignment.
- Contact Medicare or your Medicare Advantage plan to understand your potential out-of-pocket costs for both Part A and Part B.
- Ask your surgeon’s office for an estimated cost breakdown of their fees.
- Review your Explanation of Benefits (EOB) statements carefully after receiving care to ensure accuracy.
Frequently Asked Questions (FAQs)
Will Medicare pay for my surgeon if I’m in the hospital?
No, Medicare Part A covers hospital facility charges while you’re an inpatient. The surgeon’s professional fees are typically billed under Medicare Part B.
What costs will I have to pay with Medicare Part A for inpatient surgery?
You’ll likely be responsible for the Medicare Part A deductible for each benefit period. Coinsurance may also apply for longer hospital stays. It is important to understand and plan for these costs.
Does Medicare Part B cover outpatient surgery?
Yes, Medicare Part B covers outpatient surgery. This includes procedures performed in ambulatory surgical centers (ASCs) or hospital outpatient departments.
If my surgeon accepts Medicare assignment, what does that mean?
If your surgeon accepts Medicare assignment, it means they agree to accept Medicare’s approved amount as full payment for their services. You’ll still be responsible for your deductible, coinsurance, and copays, but you won’t be billed more than the Medicare-approved amount.
What if my surgeon doesn’t accept Medicare assignment?
If your surgeon does not accept assignment, they can charge you up to 15% more than the Medicare-approved amount. This is called the limiting charge.
Are there any other doctors involved in my surgery that Medicare Part B will cover?
Yes, Medicare Part B also covers fees for the anesthesiologist, any consulting physicians, and other medical professionals involved in your surgical care.
What is a “benefit period” under Medicare Part A?
A Medicare Part A benefit period begins the day you’re admitted to a hospital or skilled nursing facility and ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.
Does Medicare Part A cover pre-operative tests?
Whether pre-operative tests are covered under Part A or Part B depends on where they are performed. If they are performed as an inpatient, they fall under Medicare Part A. If they are done outpatient, they are covered by Medicare Part B.
What if I need physical therapy after my surgery?
If you receive physical therapy as an inpatient in the hospital, it’s generally covered under Medicare Part A. If you receive it as an outpatient, it falls under Medicare Part B.
How can I find out if my surgeon accepts Medicare assignment?
You can ask your surgeon’s office directly if they accept Medicare assignment. You can also use the Medicare Physician Compare tool on the Medicare website to search for providers and see if they accept assignment.
What is a Medigap policy, and how does it help with surgery costs?
Medigap policies, also known as Medicare Supplement Insurance, are private insurance plans that help cover some of the gaps in Original Medicare coverage, such as deductibles, coinsurance, and copays. Depending on the plan, a Medigap policy can significantly reduce your out-of-pocket costs for surgery.
Are there any resources available to help me understand my Medicare coverage for surgery?
Yes, you can visit the Medicare website (medicare.gov) for detailed information. You can also contact Medicare directly at 1-800-MEDICARE (1-800-633-4227). Your State Health Insurance Assistance Program (SHIP) can also provide free counseling and assistance.