Medicare Info

All patients should familiarize themselves with the terms of their insurance coverage. This will help you understand the hospital's billing procedures and charges. Important information for Medicare patients and about non-covered and covered tests/services.

What is medical necessity?
Medicare covers only those tests/services, which they feel are reasonable and necessary for your care. Medicare asks that doctors send data on your diagnosis when seeking payment so that Medicare can decide if the test/service is medically necessary. We will tell you in writing if your doctor orders tests that Medicare may not pay for. However, you will not be told in writing if the test/service is already listed in your Medicare Handbook as a test that Medicare does not cover.

What services are not covered by Medicare?
Look in your Medicare Handbook for information on tests/services that are not covered by Medicare. You will have to pay for tests/services that are not covered and for tests/services that Medicare feels are not needed for your care.

What is an ABN?
An ABN is an Advance Beneficiary Notice form. The ABN form tells you in advance that Medicare may not pay for your test/service. This form tells you which tests Medicare may decide are not reasonable and necessary for your care and tells you that you will have to pay for those services. When we give you the form, you will be asked to sign it before the tests/services are done. What options do I have?

You have two options when an ABN form is given to you (1) agree to pay for the tests/services that Medicare decides are not needed for your care and get them done, or (2) refuse to pay for the tests/services that Medicare will not cover and not get them done. If you meet the hospital's charity care rules, you may ask for help in paying for the test/service.

What are my rights as a patient?
As a Medicare patient, you have rights. These rights protect you and help see that you get needed health care tests/services. Your rights include:

  • The rights to information on what tests are covered and how much you will have to pay.
  • The right to information on your treatment options.
  • The right to appeal Medicare decisions. You also have the right to ask for help under the hospital's charity care program.

How does billing work?
Your doctor will bill Medicare when you get tests in his or her office. But, when your doctor orders tests from someone outside of his or her office, that person or facility bills Medicare for the test.

If Medicare will not pay for a test/service, does that mean I do not need it?
No. Your doctor decides what tests/services you need based on a wide range of factors like your prior medical care, drugs you might be taking and other facts. Even if your doctor feels a test/service is "good medicine," it is possible Medicare may not consider it to be medically necessary for patients with your diagnosis. When this happens, Medicare will not pay for the test/service, we will ask you to sign an ABN form, and we will bill you for the test.

What if I have questions?
If you have questions about your Medicare coverage, you should call the Healthcare Financing Administration's Medicare Information Line at 1-800-Medicare or 1-800-633-4227.

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