Nearly 20% of Americans are enrolled in Medicare and at its present rate of growth, spending on the program will soon surpass one trillion dollars a year. Drug expenses alone are over $100 billion annually. In 2020, government spending on Medicare in the United States was a little bit higher than spending on defense. And just as there have been countless stories about the army’s thousand-dollar hammers, it’s safe to say that in a government program as large as Medicare, which sends out millions of bills each month, mistakes will be made.
Sometimes those mistakes will be deliberate – Medicare fraud is estimated to be over $60 billion annually – and sometimes those mistakes are accidental: Overworked doctors or administrators put down the wrong codes or there’s a communication glitch between the medical side and the billing side.
So, what do you if you’re on Medicare and get a bill that you believe is wrong – you’re billed for a procedure you didn’t have or by a doctor you’ve never heard of – or the amount taken out of your social security is incorrect?
The first thing you should do is contact Social Security and make sure the problem isn’t on their end. If it’s clear that the issue isn’t there, try to figure if the billing problem is from a doctor’s office, hospital, nursing home, rehab, or Medicare itself. If the problem is not from Medicare, call the office of the provider who has wrongly billed you. If that doesn’t work or you’ve concluded the error is from Medicare, contact Medicare at 1-800-MEDICARE (633-4227).
With more than 60 million Americans receiving Medicare benefits, the number gets a lot of calls, so leave yourself time, be patient and if you need help, make sure someone is with you who can press all the buttons on the phone and hear the explanation from the Medicare representative.
Medicare also has an appeal process if you feel there has been a mistake in your coverage. You may appeal if you think Medicare has denied something you believe it should cover, is refusing to pay for a product or service you’ve already received, or Medicare has stopped paying for a service or product you and/or your doctor believe you still require. You may also appeal if you are in a pain management program and Medicare is limiting access to required drugs, like opioids. You will likely need proof from your doctor that the drugs serve a medical need.
The Medicare appeals process has 5 levels, and one can only assume the process is designed to wear down or confuse those who choose to use it.
Medicare.gov recommends 5 things to know when filing an appeal:
Ask your doctor, health care provider, or supplier for any information that may help your case.
If you think your health could be seriously harmed by waiting for a decision, ask for a fast decision. If the plan or doctor agrees, the plan must make a decision within 72 hours.
The plan must tell you, in writing, how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan doesn't decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.
If you believe you're being discharged from a hospital too soon, you have a right to immediate review by your Beneficiary and Family Centered Care Quality Improvement Organization (Bfcc-Qio). You'll be able to stay in the hospital at no charge while they review your case. The hospital can't force you to leave before the BFCC-QIO reaches a decision.
You have the right to a fast-track appeals process when you disagree with a decision that you no longer need services that you're getting from a skilled nursing facility, home health agency, or a comprehensive outpatient rehabilitation facility.
If you need help filing your appeal, contact your State Health Insurance Assistance Program (SHIP).
And remember, if you’re in the Qualified Medicare Beneficiary Program, you should not be billed for anything covered by Medicare, either by providers or debt collectors, and if you have paid such bills you should get your money back. Contact 1-800-MEDICARE (633-4227). If you still have a problem with a debt collector, call the Centers for Medicare and Medicaid Services at (855) 411-2372. If you are deaf or hard of hearing, call (855) 729-2372.