Medicare reimbursement is the process that delivers payments to doctors and other health care providers for the services they provide to Medicare beneficiaries. People on Medicare usually don’t file for reimbursement, but they may file a claim if the health care provider doesn’t accept Medicare.
How Does Medicare Reimbursement Work?
If you are on Medicare, you usually don’t need to submit a claim when you receive medical services from a doctor, hospital or other health care provider as long as they are participating providers.
Participating providers are those who accept Medicare and agree to Medicare’s approved price for full payment of the health care services they provide. These prices are typically less than what private insurance pays.
Medicare sets fee schedules, or a complete list of fees Medicare uses to pay doctors or other health care providers, for each covered service.
- Ambulance services
- Clinical laboratory services
- Durable medical equipment (wheelchairs, walkers, home hospital beds, etc.)
- Medical supplies
You will still be responsible for any deductible, coinsurance, copay or any other cost-sharing expense required by your Medicare coverage or plan.
How to Get Reimbursed from Medicare
While most doctors simply bill Medicare directly, some other health care providers may require you to file for reimbursement from Medicare.
You may also have to seek Medicare reimbursement if you go to a nonparticipating provider. These are doctors or other health care providers who do not participate in Medicare.
You can still go to nonparticipating providers, but they may require you to pay for their services up front. They may also charge you up to 15% more than the Medicare-approved price. You can seek reimbursement from Medicare for the approved price, but you’d be responsible for paying the rest of the cost yourself.
To receive reimbursement in these cases, you’ll need to submit a reimbursement form. You can find a copy of the Patient’s Request for Medical Payment form to download, complete and mail in at the CMS website.
You’ll also need to include an itemized bill from the health care provider.
- Date of the medical service
- Description of all medical and surgical services and any supplies
- Description of your injury or illness
- Name and address of the health care provider
- Place where the medical service was provided
- The charge for each individual service
- The health care provider’s National Provider Identifier Number
The form, itemized bill and any other documentation should be mailed to your state claim center. The addresses are included on the claim form you downloaded from the CMS website.
In most cases, any reimbursement claim must be submitted within a year of the date of your medical service.
Medicare Opt-Out Providers
In addition to participating and nonparticipating providers, there are also opt-out providers. These are health care providers who opt out of Medicare completely. They refuse to take Medicare reimbursement for any service or from anyone on Medicare.
If you receive services from an opt-out provider, you will have to pay the full cost yourself. Medicare will not reimburse you. You should check whether any health care provider you use has opted out of Medicare so you don’t receive a surprise bill.
Reimbursement for Original Medicare
You will likely not see a bill for services covered by Original Medicare. Participating providers will simply bill Medicare directly.
Medicare Part A covers hospitalization, and Medicare Part B covers outpatient medical and doctor services. You’ll still have to pay other out-of-pocket costs such as deductibles, coinsurance or copayments.
You should check to make sure the doctor or other health care provider is a participating provider before scheduling services.
Medicare Advantage Reimbursement
You should not have to file a Medicare reimbursement claim if you have a Medicare Advantage plan. Medicare pays the private companies that manage Medicare Advantage plans to handle your claims for you.
Medicare Advantage plans provide your Medicare Part A and Part B coverage. However, you should be aware that you may have to use a health care provider in your plan’s network to have full coverage.
If you use a doctor, hospital or other provider outside the network, you may be on the hook for the full cost of your medical services except in the case of a medical emergency.
If you receive care from an out-of-network doctor or hospital, you may have to pay for the services up front. You can then file a reimbursement claim with your insurance company, not with Medicare. The process for an insurance reimbursement varies from company to company.
Part D Prescription Drug Plan Reimbursement
Private insurance companies administer Medicare Part D Prescription Drug plans. Generally, these companies handle any reimbursement appeals so you don’t have to worry about filing one.
However, your Part D insurer can set their own rules about which drugs are covered and which ones you’ll have to pay for out-of-pocket.
If you think a drug should be covered, you can file an appeal beginning with your insurer. There are five successive levels of appeals. If one turns your request down, you may appeal to the next level.
- Redetermination by your Part D plan sponsor (insurer).
- Reconsideration by the Independent Review Entity.
- Hearing by an administrative law judge or attorney adjudicator.
- Review by the Medicare Appeals Council.
- Review by a federal district court.
Before filing an appeal, you should talk with your doctor to see if there is an alternative prescription medication that would work for you and that is covered by your Medicare Part D plan.
10 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2020, April 28). Opt Out Affidavits. Retrieved from https://data.cms.gov/Medicare-Enrollment/Opt-Out-Affidavits/7yuw-754z
- LaPointe, J. (2020, March 30). CMS Offers Upfront Medicare Reimbursement During COVID-19 Pandemic. Retrieved from https://revcycleintelligence.com/news/cms-offers-upfront-medicare-reimbursement-during-covid-19-pandemic
- U.S. Centers for Medicare & Medicaid Services. (2020, February 11). Retrieved from https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/Reconsiderations
- U.S. Centers for Medicare & Medicaid Services. (2020, January 8). Review by the Medicare Appeals Council. Retrieved from https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/AppealsCouncilReview
- U.S. Centers for Medicare & Medicaid Services. (2019, November 19). Fee Schedules – General Information. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo
- U.S. Centers for Medicare & Medicaid Services. (2018, January). Patient’s Request for Medical Payment. Retrieved from https://www.medicarefaq.com/wp-content/uploads/CMS-1490S-061019-readerenabled-002.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare: Provider Opt-Out Affidavits Look-Up Tool. Retrieved from https://data.cms.gov/opt-out-affidavits
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Physician Compare. Retrieved from https://www.medicare.gov/physiciancompare/
- Becker’s Healthcare. (n.d.). 100 Things to Know About Medicare Reimbursement. Retrieved from https://www.beckershospitalreview.com/finance/100-things-to-know-about-medicare-reimbursement.html
- BlueCross, BlueShield Federal Employee Program. (n.d.). Medicare Reimbursement Account. Retrieved from https://www.fepblue.org/benefit-plans/medicare/medicare-reimbursement-account