Leah Kari
Leah Kari, licensed insurance agent and retired pharmaceutical representative
You open a statement from your Original Medicare, Medicare Advantage, or Medicare Supplement Insurance plan’s explanation of benefits, and are baffled. The services you thought would be covered were not, and your share of the costs is a shock.
Health plans pay a portion of the bill for services that are covered by your plan and meet the definition of “medical necessity.” Medicare defines “medically necessary” as health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that they meet accepted standards of medicine.
There are some important questions to ask your provider before a test or procedure that will significantly lessen the medical version of sticker shock.
How much will this test, procedure, or treatment cost?
Will Medicare or my plan say this is medically necessary and pay its share? The doctor will advise which of the tests Medicare classifies as medically necessary. If Medicare does not deem a test medically necessary, you’ll pay the entire cost of the test or treatment yourself.
Do I have to have the test in the hospital or can I use labs, or imaging centers that are not part of the hospital? The adage “the bigger the building, the bigger the co-pay” applies. Ask to have services in an ambulatory surgery center or a freestanding lab versus having work done in an outpatient hospital setting.
What are the medical codes for this course of treatment? Get the codes and call your plan’s customer service department to know what will be covered and the cost. These calls are recorded, providing a record of the call’s content. Ask for a call reference number for your records.
Will everyone involved in this treatment plan be in my health plan’s network? Your provider will tell you which facility, hospital, lab, or provider will be delivering the services. Your plan’s customer service department, mobile app, or member portal will have access to the plan’s network providers, further ensuring that you will not pay unnecessary costs because providers were not in your plan’s network.
Am I formally admitted to the hospital (an inpatient), or am I under observation (an outpatient)? This is a crucial question. In the emergency room, a doctor may say that although you can leave, he would like to keep you “under observation.” Depending on your plan, “under observation” status means you will have a copay above the emergency room copay. You are not formally admitted to the hospital, and this can affect other services you may need. Your plan may have covered those costs if you had been formally admitted into the hospital. Don’t be timid in verifying this as much as you need. Your status may change without your awareness. Be certain you clearly understand this important designation.
Contact Leah Kari, AMR, FHIAS, with questions at 520-484-3807 or email [email protected]. (TTY users please dial 711.)
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