@wenfen It sounds like your doctor does not participate with Medicare, so he does not have to accept the Medicare allowance as payment in full.
Medicare pays 80%of the allowed charge, and your supplement pays the other 20%. Plan F also will pay the excess fee over and above not the Medicare allowance....so your covered services should be paid in full by your insurance.
example:
Doctor visit charge. $250
Medicare allowance. $175
Medicare Payment. $140... 80%
Plan F payment. $ 35.....20%
plus excess fee $ 75..... over and above the Medicare allowance
The non participating doctor would receive a total of $250, which is 100% of his charge from your Medicare and Plan F Insurance.
If he was participating with Medicare, he would not be able to bill the excess fee and would take the $175 payment from Medicare and Plan F and write off the $75.
The only way you would receive a bill is if this doctor was providing services that were not covered by Medicare at all.
i would make him submit all services to Medicare anyway and not pay him unless the services were denied. Never pay up front.
my DH had diagnostic services at his doctor’s office and we received a bill for some of them. I noticed that not all the services were submitted to insurance, so I called them about it. They said they would not be covered, so they didn’t submit.
I told them I needed a denial before we would pay. They submitted the charges and they were paid by insurance, but only a small amount was allowed...like $2-$4 for each test. The doctor was participating and he had to accept those low payments. He was billing us $15-$20 for each test.
Also, your Plan F only pays for deductibles and coinsurances and balances after Medicare pays. If denied by Medicare, plan F will deny too. There are some additional expenses that it covers such as foreign expenses that Medicare doesn’t pay at all.
You are eligible for a Welcome to Medicare exam within your first 12 months of Medicare. You are also eligible for a wellness exam every year you have Medicare. Certain preventative tests and shots are covered by Medicare. others like the shingles vaccine are covered by your RX insurance.
Many preventative tests and services are not covered at all, but they are covered if a covered diagnosis is submitted with the claim. For instance, If you have high blood presssure and it is listed as the diagnosis on the tests, they will be covered.
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