By Betty Berry, Tuesday, August 30, 2011 Q: When Medicare denies coverage of a service, the Medicare Summary Notice includes an explanation as to why payment is being denied. I don’t find those explanations very clear. What is the difference between “Medicare does not cover this service” and “the information provided does not support the need for this service or item”?
A: Understanding your Medicare Summary Notice is important. First, of course, it is important that you know what was billed, how much was approved for payment, what Medicare actually paid and what, if any, amount may be your responsibility.
The second reason is that as the user of the billed services, you are the first line of defense in detecting possible Medicare fraud. If the notice indicates Medicare is being billed for services or products you did not receive, you should report such discrepancies to Medicare. You can make such a report by completing the portion of the notice that allows you to report inconsistencies and returning it to Medicare.
You are not the only beneficiary who has had questions about explanations on notices. While the two explanations you mention seem, at first glance, to say the same thing, there is a difference.
Items that would receive the “Medicare does not cover this service” message include routine dental care, acupuncture, hearing aids, vision exams and cosmetic surgery.
For Medicare to cover a service, procedure or product, an existing condition must require the specific procedure or product, making it medically necessary. When receiving noncovered services, the beneficiary is responsible for the associated charges.
A message stating that “the information provided does not support the need for this service or item” appears when a service is normally covered by Medicare but is not the appropriate treatment for the particular illness or condition being treated. Let’s use an EKG as an example. Payment for an EKG will be denied if the condition being treated is the flu. However, if an EKG is billed for someone complaining of chest pains, it will be a covered service.
Doctors generally know what Medicare will cover. If it is believed that a particular service will not be covered for a specific reason, the doctor should provide an Advance Beneficiary Notice.
This is a written statement explaining why a particular service for a specific complaint may not be paid for by Medicare. When such a notice is provided, the beneficiary has the option of saying yes or no to the treatment. If the beneficiary opts to have the treatment and Medicare denies payment, the beneficiary is responsible for those charges. Make sure you understand any Advance Beneficiary Notice you are asked to sign.
If you receive either type of message and believe it is in error, you have the opportunity to ask Medicare to review its decision. You might also want to talk with your physician to see if there is more information about that particular service or product that could be provided to Medicare to be used in reviewing its initial decision.
It is most important that you review your Medicare Summary Notice to be sure your health care providers are billing Medicare for services actually provided. Some billing errors are mistakes, while others could be the result of fraud. Make it your responsibility to ensure charges billed to Medicare on your behalf are accurate.
Sept. 7, 1-3 p.m.: Seminar, “Will You Pass Your Next Driving Test?” Moorpark Active Adult Center, 799 Moorpark Ave., Moorpark. For information and reservations, call 517-6261.
Sept. 14, 1:30-3 p.m.: Seminar, “Are You Prepared to Be a Caregiver?” Westlake Village Civic Center, 31200 E. Oak Crest Drive, Westlake Village. For information, call 495-6250.
Betty Berry is a senior advocate for Senior Concerns. The advocates are at the Goebel Senior Adult Center, 1385 E. Janss Road, Thousand Oaks, CA 91362; phone 495-6250 or email email@example.com. Please include your telephone number. You are invited to submit questions on senior issues.