UNITED STATES—Hello Toni, I have a $2,000 doctor bill with a new cardiologist and Medicare says they will not pay. I recently retired and enrolled in Medicare and a Medicare supplement for the freedom to pick my own doctor!

This is too confusing for me. I need some advice…Thanks, Joey from Cleveland, OH.

Hello Joey: I rarely see a problem with doctor’s/provider’s bills, but when it does happen, there is a process you must follow to find out if the office visit or procedure will be paid as a “Medicare approved” service.

If Original Medicare will not pay for care you received, you can find this out by visiting www.medicare.gov and opening a Medicare.gov account to view your Medicare information and medical claims. For those not able to open a Medicare.gov online account, you can wait until you receive your Medicare Summary Notice (MSN). The MSN is not a bill.

Medicare Summary Notices (MSNs) are mailed four times a year and contain information about submitted charges, the amount that Medicare paid, and the amount you are responsible for. MSNs are used only with “Original Medicare” and not with Medicare Advantage or Medicare Part D Prescription Drug Plans.

 Below is what you should do if you believe the claim is medically necessary:

  • Find out if it is possible that there was a billing mistake. Medicare uses a set of service codes, called CPT/HCPCS codes, for processing medical claims. Each medical service has been assigned a specific code. Sometimes providers accidentally use the wrong codes when filling out Medicare paperwork, and this can result in Medicare denials. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct code(s). Your doctor’s billing office can call 800-MEDICARE (800-633-4227) to verify the code. If a wrong code was used, ask your doctor to resubmit the claim with the correct code(s).
  • If the medical provider believes the claim was correctly coded or is unwilling to refile the claim, your next step is to appeal. Appealing is easy and many Americans win! The MSN will have instructions on how to appeal. Follow the instructions or call 1/800-MEDICARE (800-633-4227) for help. If the MSN lists items and you are not disputing all of them, circle the one you want to appeal. Write “Please Review” on the bottom and sign the back. Make a copy for your files. Then mail the signed original to Medicare at the address on the MSN. Make sure you mail your appeal within 120 days of receiving the MSN. Do NOT wait past the time to appeal!
  • If possible, get a letter from your healthcare provider stating the service was necessary and why. Send this with your MSN.
  • Call Medicare if you need help filing an appeal at 1-800-633-4227. Normally, the wait to speak to a Medicare agent isn’t as long as the Social Security 800 number wait time and Medicare is eager to help solve your issue.

**Always keep photocopies and records of all communication, whether written or oral with Medicare concerning your denial. Send your appeal certified mail and make sure you ask the post office or UPS/FEDEX for a signed delivery confirmation. **

Remember, with Medicare… what you don’t know WILL hurt you! Need Medicare help? Call the Toni Says Medicare hotline at (832) 519-8664 or email info@tonisays.com for assistance.

Toni is offering a $10 discount on her book, the “Medicare Survival Guide Advanced” edition, to all Toni Says® readers and their friends at www.tonisays.com and www.seniorresource.com. Also visit www.seniorresource.com/medicare-moments/ to listen to Toni’s Medicare Moments podcasts.

The 2023 Medicare Prescription Drug Survival Guide is available at no cost by visiting www.tonisays.com.