Most Medicare Advantage plans have set co-pays for services like doctor visits and outpatient surgery. This plan design should make it simple for people to understand the bills they receive from doctors, hospitals, and outpatient surgery facilities.
Yesterday I got a call from Shirley, who is enrolled in a Medicare Advantage plan. She had surgery on her foot at an outpatient surgery facility. She paid the $150 co-pay as required by her Advantage plan – and that’s a good deal.
A month after her surgery, Shirley got a bill saying she owed $75 for anesthesia and $100.78 for a doctor’s assistant. Whaaat?
When I enroll someone in a Medicare Advantage plan, I tell them to call me if they have any problems, like an unusual bill they receive from a provider, or a problem getting prior authorization for a test.
Thank goodness Shirley remembered my advice – because she should not be getting those bills. It sounds like the Shirley was being “balance billed” – and that should not happen to people who are enrolled in Medicare Advantage plans.
I asked Shirley if she had spoken to her Medicare Advantage plan’s Member Services, and she said she had. The person she spoke with said she probably owed those bills. Whaaaat?
I called Shirley’s plan and I was instructed to tell Shirley to call Member Services again and hope she gets somebody who knows what they’re talking about.
Shirley made the second call and talked a another (more experienced?) representative who told her she should not have to pay those bills. Shirley was told her plan would talk to the billing department for the two different doctor groups who were balance billing her. Her Advantage plan would get this problem fixed.
I asked Shirley if the Member Services rep said he would get back to her, but Shirley said this did not happen. Hopefully all this does get resolved – and quickly. You see, hospitals, doctors, and medical groups do not wait around to get paid. They very quickly turn over unpaid bills to collection agencies, and collection agencies quickly send negative reports to credit rating companies. Here is one such story.
Shirley is pretty sharp, and she has kept the Summary of Benefits and the Evidence of Coverage for her Medicare Advantage plan. She referred to the Evidence of Coverage (100+ pages) when she spoke to the billing department for the doctor group, but they were not swayed. They said she owed the money.
I told Shirley it was up to her Medicare Advantage plan to fix this problem because they have a contract with the surgical facility that says they will pay a certain amount for each medical service. I would assume the contract says they should not balance bill the patient.
Important lesson #1: People need to know how their Medicare Advantage plan works, so they don’t end up paying bills they don’t owe.
Important lesson #2: If you don’t get the answer you think you should get from your Advantage plan’s Member Services, try calling again. It is possible you spoke to an inexperienced employee who gave you the wrong answer. You could also ask to talk to a supervisor if you are pretty sure that rep is wrong.