Problem:

Mrs. B’s gynecologist took Medicare but did not accept Medicare assignment. Doctors who do not take assignment do not have to accept Medicare’s approved amount as payment in full. They can charge up to 15% above the Medicare-approved amount for their services. They can also ask their patients to pay for services up front. Mrs. B was paying her gynecologist up front. Medicare had never reimbursed her for the service. Mrs. B called Medicare to find out why she had not been reimbursed and found out that her gynecologist had never submitted a bill to Medicare.

What To Do:

Mrs. B called her local State Health Insurance Assistance Program (SHIP) hotline for help. A SHIP counselor informed Mrs. B that doctors who participate in Medicare, even if they do not accept assignment, are required by law to bill Medicare for services provided to people with Medicare. The counselor called the doctor’s office and reminded her staff of this rule. She then called 800-MEDICARE and flagged the problem with a Medicare representative. After the SHIP counselor contacted the doctor’s office and Medicare, the doctor billed Medicare and Mrs. B was reimbursed for the service.

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