How Doctors Bill Medicare Supplement Plans: A Comprehensive Guide
Doctors bill Medicare Supplement plans (Medigap) by first billing Original Medicare. If Medicare approves the claim, they will then automatically forward the remaining balance to your Medigap insurer for payment, streamlining the process for both doctors and patients.
Understanding Medicare Supplement (Medigap) Plans
Medicare Supplement plans, often called Medigap, are private insurance policies designed to help cover the “gaps” in Original Medicare (Part A and Part B). These gaps include things like deductibles, coinsurance, and copayments. Unlike Medicare Advantage plans, Medigap plans typically allow you to see any doctor that accepts Medicare, nationwide, without needing referrals. The core benefit of these plans is financial protection against unpredictable healthcare costs.
Benefits of Medigap for Patients and Providers
Medigap offers significant benefits for both patients and healthcare providers.
- For patients: Medigap provides greater predictability in healthcare expenses and access to a wider network of doctors. They provide peace of mind knowing a large portion, or even all, of out-of-pocket costs are covered.
- For Providers: Medigap simplifies the billing process because the vast majority of plans pay automatically after Medicare. This reduces the administrative burden on doctors’ offices.
The Billing Process: Step-by-Step
How do doctors bill Medicare Supplement plans? The process is generally straightforward:
- Patient presents Medicare card and Medigap card: The doctor’s office verifies the patient’s coverage with both Medicare and the Medigap insurer.
- Doctor submits the claim to Medicare: The doctor bills Original Medicare (Parts A and/or B) directly. They use the standard Medicare claim forms and electronic billing systems.
- Medicare processes the claim: Medicare reviews the claim and determines the approved amount.
- Medicare pays its share: Medicare pays its portion of the approved amount to the doctor. This is typically 80% for Part B services.
- Medicare forwards the claim to the Medigap insurer: Medicare automatically transmits the claim information (including the remaining balance) to the patient’s Medigap insurer.
- Medigap insurer processes the claim: The Medigap insurer reviews the claim.
- Medigap insurer pays the remaining balance: The Medigap insurer pays the remaining balance (or the portion covered by the specific plan) directly to the doctor.
- Doctor receives payment: The doctor receives payment from both Medicare and the Medigap insurer, covering the full amount for covered services (depending on the plan specifics).
Common Mistakes and Challenges
While the billing process is generally automated, errors can still occur.
- Incorrect patient information: Ensuring accurate Medicare and Medigap policy information is crucial.
- Billing errors: Doctors’ offices should be meticulous in coding and submitting claims accurately.
- Non-covered services: Medigap plans may not cover all services. It’s essential to verify coverage before receiving treatment.
- Medigap plan coverage: Some Medigap plans have lower levels of coverage than others (Plans K & L, for example) so knowing your specific plan is crucial.
Streamlining the Billing Process for Doctors
Several strategies can streamline the billing process for doctors:
- Utilize electronic billing systems: These systems automate claim submission and tracking, reducing errors and delays.
- Verify patient coverage proactively: Confirming coverage with both Medicare and the Medigap insurer before treatment can prevent billing issues.
- Stay updated on Medicare and Medigap regulations: Healthcare providers must stay informed about changes in billing rules and coverage policies.
- Use clearinghouses: Clearinghouses act as intermediaries between healthcare providers and insurers, verifying claims and ensuring accurate submission.
Comparing Medigap Plans
| Feature | Plan G | Plan N | Plan F (if eligible) |
|---|---|---|---|
| Part A Deductible | Covered | Covered | Covered |
| Part B Deductible | Covered | Covered | Covered |
| Part B Coinsurance | Covered | Covered (except co-pays) | Covered |
| Part B Excess Charges | Covered | Covered | Covered |
| Out-of-Pocket Limit | None | None | None |
| Cost | Generally Higher | Mid-Range | Generally Highest (If available) |
Note: Plan F is only available to those eligible for Medicare before January 1, 2020.
How Do Medigap Plans Coordinate with Medicare?
Medigap plans are designed to work in tandem with Original Medicare (Parts A and B). Medicare pays its portion of approved healthcare costs first, and then your Medigap plan steps in to cover some or all of the remaining out-of-pocket expenses, depending on the specific plan benefits. This eliminates the need for complicated coordination on the part of the patient or doctor, making the process seamless for approved treatments.
What happens if a doctor doesn’t accept Medicare?
If a doctor doesn’t accept Medicare (is a non-participating provider), neither Medicare nor your Medigap plan will pay for their services. You would be responsible for the full cost of treatment. It’s crucial to confirm that a doctor accepts Medicare before receiving care to ensure coverage.
Do I need to file claims myself with a Medigap plan?
In most cases, you do not need to file claims with your Medigap insurer. Medicare automatically forwards the claim information to your Medigap plan for processing. This is a major advantage of Medigap plans, simplifying the billing process for beneficiaries.
What are Medicare “excess charges,” and how do Medigap plans handle them?
Medicare “excess charges” are the difference between what a doctor charges and the amount Medicare approves for a service. Doctors who don’t accept Medicare assignment can charge up to 15% more than the Medicare-approved amount. Some Medigap plans, such as Plan G and Plan F (if you are eligible), cover these excess charges, while others, like Plan N, do not. Understanding if your plan covers excess charges is critical.
How does a Medigap plan differ from a Medicare Advantage plan?
Medigap and Medicare Advantage are very different. Medigap supplements Original Medicare, paying for cost-sharing. Medicare Advantage replaces Original Medicare, and you typically need to use network doctors and can face co-pays. How do doctors bill Medicare Supplement plans is different from how they bill Medicare Advantage. Medigap gives you more freedom, while Advantage can be more affordable but may have network restrictions.
What should I do if I receive a bill that I believe is incorrect?
If you receive a bill that you believe is incorrect, contact your doctor’s office and your Medigap insurer immediately. Gather all relevant documentation, including your Medicare card, Medigap card, and the bill in question. Explain your concerns and ask for clarification. Most billing discrepancies can be resolved with clear communication and documentation.
Are all Medigap plans standardized?
Yes, Medigap plans are standardized across the country, which means that Plan G, for example, offers the same basic benefits regardless of which insurance company you purchase it from. The primary difference between companies is the monthly premium. (Massachusetts, Minnesota and Wisconsin have different Medigap plans).
What does it mean for a doctor to “accept assignment”?
When a doctor “accepts assignment,” it means they agree to accept the Medicare-approved amount as full payment for their services. This means they cannot charge you more than the Medicare-approved amount, simplifying the billing process and reducing out-of-pocket expenses.
Can I switch Medigap plans at any time?
While you can apply to switch Medigap plans at any time, acceptance isn’t guaranteed, unless you have a guaranteed issue right. Guaranteed issue rights occur during specific situations, such as losing coverage from another plan or moving out of a Medicare Advantage plan’s service area within the first 12 months. Outside of guaranteed issue periods, insurance companies can deny coverage based on your health.
Does Medigap cover prescription drugs?
Medigap plans generally do not cover prescription drugs. To obtain prescription drug coverage, you need to enroll in a separate Medicare Part D prescription drug plan. It is very important to consider prescription drug coverage when choosing supplemental insurance, as there are penalties for not having creditable drug coverage when you become eligible.
Are there any enrollment periods for Medigap plans?
The Medigap Open Enrollment Period is a one-time period that begins when you are 65 or older and enrolled in Medicare Part B. This period lasts for six months, and during this time, you are guaranteed acceptance into any Medigap plan regardless of your health. Outside of this period, getting accepted into a Medigap plan may depend on your health status.
What is the best way to find a doctor who accepts my Medigap plan?
Since Medigap plans generally allow you to see any doctor who accepts Medicare, you can use the Medicare’s “Find a Doctor” tool to locate providers in your area. You can also contact your Medigap insurer for a list of providers that accept Medicare and verify whether they have any preferred provider networks (although most Medigap plans do not). When scheduling your appointment, always double-check with the doctor’s office that they accept Medicare and your specific Medigap plan. This will help ensure a smooth billing process and prevent any unexpected costs.