Among Friends

[Mom2Dogs]

I have been on Medicare for 3 years and never met my yearly deductible, but since I had an injury, surgery and follow up visits I am sure that in 2024 I will meet the deductible.

The question is the formula of how Medicare figures how much they pay per visit/procedure.  

If I have a doctor bill for $100.00 how does Medicare figure out how much to apply to my deductible? Is there a percentage they pay vs what I am responsible for?

My insurance agent told me I should keep track just in case there is an error in billing....I did not think to ask him this question when we talked.

thanks

[LTT1]

@Mom2Dogs 

I would try calling whoever manages your medical insurance plan (for me it is AARP for United health care). There is a phone # on the back of your insurance card one can call and request help from them.

[Desert Lily]

If you have an Advantage plan or a Supplement plan, I'd check with them on what you might possibly owe in the future. Plans differ.

I'd contact Medicare directly if you want specifics from them on how they calculate what they pay out. The Medicare website may have some info &/or the Medicare & You booklet Medicare recently mailed.

[TVLand]

The deductible amount for Part B for 2024...is $240.   I don't know how the percentage is calculated...but I do know your deductible does not apply to one doctor visit..it .is divided between a few doctors visits....

[Mom2Dogs]

@TVLand   @Desert Lily   @LTT1  I did check with my supplement plan.... they told me to contact medicare, so I called.  She did not know how the deductible is figured for each bill either, some providers write charges off some do not, so I guess there is no 'formula'.  I find it confusing.

What prompted the question is the amount I see that medicare paid and what my supplement paid for my recent injury and surgery.   Since I have never met my yearly deductible since being on mediare I wanted to understand.

 The rep did tell me I had met my 2023 deductible on Dec. 7.

That makes me 'think' that since I have PLAN G/supplment I should not owe any more for the doctor charges that I incurred the rest of december 2023....but when I look at my supplement  EOB on line I still owe quite a bit of money...but have not received any bills yet.

I understand that the deductible starts over again in 2024.

[Mindy D]

---

@Mom2Dogs wrote:

I have been on Medicare for 3 years and never met my yearly deductible, but since I had an injury, surgery and follow up visits I am sure that in 2024 I will meet the deductible.

The question is the formula of how Medicare figures how much they pay per visit/procedure.  

If I have a doctor bill for $100.00 how does Medicare figure out how much to apply to my deductible? Is there a percentage they pay vs what I am responsible for?

My insurance agent told me I should keep track just in case there is an error in billing....I did not think to ask him this question when we talked.

thanks

---

@Mom2Dogs @You had all of this in January of 2024? 

[Mom2Dogs]

@Mindy D  No, the injury and surgery were in 2023/early December.

The EOB's just started showing up on my supplement page on line.  

I know that the deductible starts over Jan. 1 of each year.

[on the bay]

@Mom2Dogs,

I have never understood deductables just like I never got how to put pictures on computer and transfer them here!

But one thing I've learned is from bills and calling is that sometimes, the supplement or plan aside from Medicare has not yet been submitted.

I also always check with the provider to make sure they have filed the claim with both my insurances and also that they have the correct code and correct insurance.

I understand that doctors who take medicare have agreed to accept the payment that medicare has agreed to pay. The patient should not have to pay the part that Medicare didn't pay for but sometimes the doctor ignores that.

These are the things I've learned after getting bills that I don't think I should have gotten.

And most all the time, I am correct and the bill is reversed or they resubmit the claim correctly.

[Mom2Dogs]

@on the bay   Thanks, generally I pay a bill as soon as I get it but for this injury, I am going to make sure I owe what I owe...I find it hard to believe I would ever get a refund if I overpaid.

According to the insurance broker that helped me purchase my supplement he told me that all I should ever owe (according to my supplement plan G) is my monthly supplement and the medicare deductible.

I do realize that medicare does deny some claims, but those can be delt with when they arise...my shoulder er visit, surgeon visit, surgery and follows ups are a different matter....holy smokes it was an expensive fall!!!

[Icegoddess]

If the services were provided in 2023, even if they are paid in 2024, they will go against your 2023 Deductible.

Part A is for hospital/in-patient services.

Part B is for out-patient/medical coverate

Plan G covers the Part A Deductible.  The $240 Part B Deductible is also your Plan G's deductible.  That's different for most other plans as I understand it.  Your Plan G insurance will also cover excess charges.  In other words, if the provider charges more than what Medicare covers, your insurance will cover it, not you.  

The main exception I know of is that if the provider does not participate with Medicare, you may get stuck with those charges.  

I'm new to Medicare, so all of this is still rather confusing, especially since I'm also healthy.  I never met my deductible under my ACA insurance, but that was in the order of $7500/yr. 

My advice would be to not pay your provider until you know whether Medicare and your Plan G Insurance has paid.  If you have met your Deductible after that, then you'll have to do some homework to figure out whether you are responsible for any charges your provider bills you for.