How to Fix Medicare Billing Issues: A Step-by-Step Guide

Why Medicare Billing Errors Happen

Medicare billing errors are all too common. They can stem from various causes, including incorrect billing codes, duplicate charges, or services not covered by Medicare.

Understanding these issues and taking steps to address them can save you time, stress, and potentially money. Here’s a straightforward guide on how to address Medicare billing problems as effectively as possible.

A Solace advocate can help overturn insurance errors

Common Medicare Billing Errors to Watch For

Here are some of the most frequent Medicare billing errors that can lead to unexpected charges:

• Incorrect Billing Codes: Mistakes in procedure or diagnosis codes, leading to higher or unnecessary charges.
• Duplicate Charges: Occurs when the same service is billed more than once.
• Unrendered Services: Billing for services you didn’t receive.
• Medicare Denials: When Medicare denies coverage for a service due to misunderstandings or incomplete documentation.

The good news is that these issues are often resolvable.

Step 1: Review Your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB)

The Medicare Summary Notice (MSN) and Explanation of Benefits (EOB) outline the details of services billed to Medicare, along with what Medicare covered and what you may owe. Here’s how to review them:

• Compare Services: Ensure the services listed match those you received.
• Check Amounts: Confirm that Medicare’s coverage and adjustments are correct.
• Look for Denial Codes: Codes on your EOB can indicate why a claim was denied or partially covered.

Reviewing your MSN and EOB carefully is the first step to spotting billing discrepancies.

Pro Tip: Keep all MSNs and EOBs organized so you can track and reference them if billing issues arise. Easily do this with Solace’s dashboard. Get your advocate today.

Step 2: Contact the Provider for Clarification

If you notice a discrepancy, start by contacting the billing department of the healthcare provider who issued the bill. This can often resolve issues directly.

• Ask for an Itemized Bill: Sometimes, bills lack detail, so an itemized version can clarify what each charge is for.
• Discuss Errors or Misunderstandings: Providers may correct errors like duplicate charges or code mistakes without needing Medicare involvement.
• Document the Conversation: Note the representative’s name, date, and what was discussed to keep a record.

A Solace advocate can help explain billing issues.

Step 3: Check Medicare Coverage for Services Billed

If there are charges Medicare didn’t cover, it’s essential to check if those services are generally covered by Medicare. You can use the Medicare Coverage Database on the Medicare website to search for coverage information.

• Compare Services to Medicare Coverage: Determine if the service billed should be covered under your Medicare plan.
• Medicare Advantage or Part D Plans: If you have a Medicare Advantage or Part D plan, confirm with your provider or insurance company, as coverage rules may differ.

Understanding Medicare coverage helps you determine whether the billing issue is a true error or a lack of coverage for the service.

Step 4: Dispute Errors with Medicare

If you cannot resolve the issue with the provider, you can file a dispute with Medicare to address billing discrepancies.

• Contact Medicare Directly: Call 1-800-MEDICARE to report the issue, and have your MSN or EOB ready to reference.
• Submit a Dispute in Writing: If the phone call doesn’t resolve the issue, you can submit a written dispute with supporting documentation.
• Include Documentation: Attach relevant documents, such as the MSN, EOB, itemized bill, and any notes from conversations with the provider.

Be clear and concise in your explanation, outlining the issue and why you believe it’s an error.

Tip: For complex disputes, work with a Solace advocate who specializes in Medicare billing.

Step 5: When to Consider Filing a Formal Appeal

If Medicare denies your dispute, you can file a formal appeal to review your claim further. The appeals process includes several levels, starting with a redetermination and potentially escalating to an independent review.

• First Level Appeal (Redetermination): This is a request for Medicare to reconsider its decision. Submit the appeal within 120 days of receiving your MSN or EOB.
• Higher Levels of Appeal: If the redetermination is denied, you may request a reconsideration by an independent contractor, followed by a hearing with an Administrative Law Judge (ALJ) if necessary.

Each appeal level has specific deadlines, so it’s essential to file on time and track each step.

A Solace advocate can craft your appeal.

FAQ: Resolving Medicare Billing Issues

What should I do if I don’t understand my bill?

Start by reviewing your Medicare Summary Notice (MSN) and Explanation of Benefits (EOB). If something is unclear, ask the provider for an itemized bill and explanation.

How long do I have to dispute a billing issue?

You generally have 120 days to request a redetermination, which is the first step in Medicare’s appeals process. Timelines for each step in the appeal process vary, so check deadlines carefully.

Can Medicare billing errors be corrected over the phone?

Yes, minor errors can often be corrected by contacting Medicare or your healthcare provider by phone. Keep a record of your conversation and follow up in writing if necessary.

What happens if my dispute is denied?

If your dispute is denied, you can appeal the decision through Medicare’s formal appeals process, which involves multiple levels of review, starting with a redetermination.

Who can help if I need support with Medicare billing issues?

A healthcare advocate can provide expertise in resolving Medicare billing issues, including disputes, provider communication, and managing the appeals process.

Medicare billing issues can feel overwhelming, but with these steps, you’ll be better prepared to identify errors, clarify charges, and take action to resolve disputes.

Work with a Solace advocate if you need additional support. Having an expert on your side can make the process smoother.