Do you like unexpected bills? If your answer was a resounding “NO” (pretty sure most of us hate surprise bills), then you will love today’s topic. We’re diving into the issue of Medigap Plan G unexpected medical bills, and teaching you how to avoid them. Let’s get started.
Medigap Plan G
For the sake of our topic, we’re going to assume you have a Medigap Plan G policy, meaning you bought a Supplemental Plan G. Let’s quickly review what that means.
When you enroll in Medicare, you can either stay in original Medicare A and B and get a Supplemental plan to help fill in the gaps in coverage, or you can opt for a replacement (Advantage) plan.
When you stay in original Medicare and get a Supplemental Plan, Medicare is in the first payor position and the Supplemental insurance company is in the second payor position. In other words, Medicare pays first, and then the Supplemental plan comes along and covers the gaps Medicare doesn’t pay for. Supplemental Plan G will cover all the gaps except for the Medicare Part B deductible, which is $230 as of 2022.
Medigap Plan G: Unexpected Medical Bills
We’re going to look at a few examples of why you might get unexpected medical bills, plus what to do if this happens.
Part B Deductible
Let’s suppose you have a Medigap Plan G (which means you should only be responsible for your Part B deductible), but you get a surprise medical bill in the mail for $220. When you look at your bill’s explanation of benefits, you realize that Medicare only paid $18 and your Supplemental plan only paid $4. That leaves you to cover $198, which is the exact amount of your Part B yearly deductible.
For this example, you ended up with a bill simply because you hadn’t yet met your yearly deductible. After you pay that $198, Medicare and the Supplemental plan should kick in and cover the rest. So the first question you should always ask when you get a surprise medical bill is, have I met my Part B deductible this year?
Coding Error
Let’s suppose you undergo an outpatient procedure that was approved by Medicare for $1,000. After the procedure, you get a bill in the mail for $1,000. On the explanation of benefits, you see that Medicare paid $0, meaning you are now responsible to pay the full bill.
The first thing we would encourage you to do is make sure you’ve met your part B yearly deductible of $230. If you’ve already met the deductible, the next thing you need to do is determine if the procedure was truly covered by Medicare. If you confirm Medicare should have covered it, then you (or your insurance firm) will need to call the doctor’s office, surgical center, or outpatient center that conducted the procedure (they’re the ones that billed you, not Medicare).
You (or your insurance firm) will call and ask them to go back and look at the claim they sent to Medicare to make sure it was coded correctly. When there’s a surprise bill like this, ninety-nine percent of the time the medical billing office realizes they made a coding mistake with the Medicare claim, which is why Medicare and the Supplemental plan denied the claim. Once you’ve caught it, the provider will correct the code and refile the claim with Medicare. Medicare will adjust their payment and you’ll no longer have to worry about paying the $1,000 surprise bill.
Medicare Covered Service
For this final example, let’s say you go to a chiropractor and the chiropractor adjusts your spine and does an x-ray. While at the chiropractor’s office, you also get acupuncture. In the end, the chiropractor’s office bill is $40 for the adjustment, $125 for the x-ray, and $85 for the acupuncture, all totaling $250.
Now let’s say you get a bill in the mail that says you’re responsible to pay for $210 of the $250 bill. You’ve already met your Part B yearly deductible and everything was coded correctly. So what happened?
You got a service that was not covered by Medicare. While spine adjustments are covered by Medicare, x-rays and acupuncture are not. So you are financially responsible for $210 of the bill.
As you can see in this instance, there’s nothing more you can do to appeal the unexpected bill. Medicare doesn’t cover these services, so you’re left to pay for them out of your own pocket.
Conclusion
If you’re on a Medigap Plan G and you get a surprise medical bill, start by asking these three questions to determine why you got the unexpected bill and what you can do to appeal it:
- Have I met my Part B yearly deductible yet?
- Was the bill coded and sent to Medicare correctly?
- Was the service/procedure covered by Medicare?
We understand how difficult making the right Medicare decisions can be. To take the next step, watch our full course here, or schedule a free one-on-one call with a certified Medicare School Guide who can answer your questions, compare plans options, and even help you enroll. Click here to get started.