Will Medicare Cover my Procedure?
At some point every Medicare beneficiary will face the same question… "Will Medicare cover my procedure?" To best answer this and save you from unexpected bills we need to understand what constitutes “Medical Necessity” and how to choose a provider.
Defining Medical Necessity
Medicare's decides whether or not to cover a procedure on the principle of it being a "medical necessity." This refers to the procedure, services, or supplies being essential for diagnosing or treating an illness, injury, or condition that aligns with accepted medical standards. For instance, while cosmetic procedures like plastic surgery aren't covered, there are exceptions. A prime example is Botox. While typically not covered when used for cosmetic purposes, Botox can be covered when prescribed for medical conditions like migraines.
If a doctor submits documentation stating that a procedure is medically necessary for treating a specific condition, then Medicare is likely to cover it.
Choosing the Right Healthcare Provider
Your choice of healthcare provider plays a pivotal role in determining your out-of-pocket expenses. Medicare classifies providers into three categories:
Participating Providers: These professionals accept Medicare's assigned rates. Opting for them ensures Medicare covers the cost of the procedure, and you're not left with any surprise bills.
Non-participating Providers: While they accept Medicare, they don't necessarily agree with its rates. They can charge up to 15% more than what Medicare covers, potentially leaving you with “excess charges”.
Opted-out Providers: Any care from these providers won't be covered by Medicare at all. It's crucial to be aware of this to avoid hefty bills.
Stick with participating providers to make sure your care is covered by Medicare. If you have certain supplemental insurance plans (F or G) you may also have care by non-participating providers covered.
Avoiding Unexpected Bills
Unexpected medical bills can be a source of significant stress. Two common causes are providers billing before Medicare processes the payment and miscoding of procedures. To safeguard against these pitfalls:
Always inquire upfront if Medicare covers the procedure you're about to undergo.
Leverage tools like Medicare's "What's Covered" app to gain clarity on coverage.
Should you receive a bill that seems off, don't rush to pay. Consult with customer service or the billing department to ensure accuracy. Often, a simple coding error can be the culprit behind an unwarranted bill.
Being proactive and informed about Medicare coverage is not just about avoiding unexpected bills; it's about ensuring you receive the care you deserve. While Medicare provides foundational coverage, it has its limitations. Supplemental insurance or "Medigap" plans can fill in the gaps and offer more peace of mind. As you navigate Medicare always verify, research, ask questions, and reach out to our licensed insurance agents for free personalized guidance. Your health and wallet will thank you.
