In some situations, your health care provider may be unable or unwilling to bill Medicare. For example, your doctor could be a non-participating provider that does not accept Medicare’s approved amount for a service as payment in full and refuses to file a Medicare claim.
If your provider does not think that a service will be covered by Medicare for you, she may have you sign an Advance Beneficiary Notice (ABN). When you sign the ABN, there will be an option on the ABN to check whether or not you want your doctor to submit a claim to Medicare for the service. You should always select that you want your doctor to submit the claim to Medicare. If you do not, your doctor is not required to submit the claim. You should check this option, because Medicare may still pay for the services after all.
If you sign an ABN but ask your doctor to bill Medicare, and Medicare then denies coverage, you can always appeal.
If you have to pay up front for your appointment because your provider refuses to bill Medicare, you should take action. A refusal to bill Medicare at your expense is often considered to be Medicare fraud and should be reported. You can report the problem to
- the administrators at the place where your doctor or medical equipment supplier works;
- your Medicare Part B carrier;
- Medicare Administrative Contractors (MACs);
Note: In 2008, Medicare began replacing fiscal intermediaries, carriers and regional home health intermediaries with Medicare Administrative Contractors (MACs). These MACs will process claims for both Medicare Part A and Part B in assigned regions. There are 15 A/B MAC regions. To find out who you should call with billing issues and whether your state has been assigned to a MAC region, call 1-800-MEDICARE.
- your local durable medical equipment Medicare administrative contractor (DME MAC) for problems with a medical equipment supplier;
- your State Attorney General’s office;
- your state medical licensing board.
Health care providers will be reprimanded for their refusal to follow Medicare policy and may lose their right to bill Medicare altogether.
If your provider continues to refuse to bill Medicare or is unable to do so, you may file a Medicare claim yourself as a last resort. Submit a Patient’s Request for Medicare Payment form (also called the CMS-1490S form) to your Medicare Part B carrier. You must send bills or receipts for the service along with the form. Claims submitted in this way may take much longer to process than they would if they were submitted by your provider.