Hi Toni:
I am new to Medicare and this week, I went to see my primary care doctor and his office said that since Medicare is primary on my insurance, I would have to pay the complete bill and file the claim with Medicare myself.

 I am 68 years old and decided to retire with a May 1st effective date.  I do not have serious health issues and this concerns me for future healthcare.

Can you please tell me what I need to do to submit this doctor visit and get reimbursed?

Thank you so much –Sam…Kingwood


Hello Sam:

Many of the smaller medical providers, whether a primary care or a specialist are opting out of the Medicare system. They want you to submit the bill to Medicare and wait to be reimbursed. This is not the first time I have heard of this situation.

Did the doctor charge Medicare rates or their rates and want you to be reimbursed from Medicare what Medicare will pay?  That is what it sounds like to me.

I am hearing through the Medicare grapevine from clients that visit the Toni Says® office for their Medicare consultation. I have learned that the older primary care and medical providers are retiring because the office paperwork, whether it is Medicare or under 65 Affordable care medical claims, is overwhelming.

My advice to clients who are new to Medicare and do not have a primary care physician is to begin searching for medical providers before going on Medicare. Be prepared, especially when a serious health issue is involved. I rarely hear about this type of problem with larger medical offices, especially those who are part of a hospital system.

Below are a few Toni Says® Medicare tips that a Toni Says® agent tells clients when searching for a new medical provider:

  • Before you set the appointment for your medical visit, ask the doctor’s office, if they are accepting new Medicare patients?
  • Does the provider or facility accept Medicare assignment and will the office or facility bill Medicare directly?
  • If they say NO, then you need to decide…Do I want to pay out of pocket and get reimbursed what Medicare pays?  Doctors know they are not paid their asking rates.  Medicare is not the only one who discounts the doctor’s bills.  Group and individual health insurance plans with network providers also discount the doctor’s bills…. OR…
  • Look for a doctor or specialist that does take Medicare assignment and will bill Medicare.  There are plenty of doctors and healthcare professionals that still accept and bill Medicare and are accepting new Medicare patients.  Even top in their specific medical field specialists still take Medicare.

Here is how to file a claim if your doctor doesn’t accept Medicare assignment:

  • You may have to pay the complete bill and submit the claim to Medicare.
  • Look in the Medicare & You handbook which explains how to submit a claim.
  • Call 1/800-MEDICARE (633-4227) and ask for Form CMS-1490S or go to medicare.gov/medicareonlineforms.
  • When talking with Medicare, ask them for help with filing the claim and they will be happy to assist.

Understanding Medicare can be very complex. Visit www.abbs4u.com (American Baby Boomers Society) or the 2018 Medicare & You handbook for more information on Medicare.

Toni King, Medicare Advocate, Founder/CEO of American Baby Boomers Society and author of the 2018 Medicare Survival Guide® Advanced edition which is available at the ABBS4U.com or ToniSays.com . If you have any Medicare questions, please feel free to reach out at www.abbs4u.com office for Toni at 844-250-8664 or email info@tonisays.com.