HOW TO READ A BILL: Understanding the Medicare Summary Notice

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Note: the videos linked below originally appeared on our Youtube channel.  We present it on our page in higher quality and with a video transcript for your convenience.  If you would like the original posts:

Part A     Part B             Durable Equipment

The Medicare Part A Summary Notice

We get a lot of questions.  Some specific to a client’s needs, others are more general.  But one of the most important questions we get asked is simply: how do I read my bill?  So I made up a three part series covering how to read your Medicare bill.  This is a very important skill and covers everyone who remains on original Medicare (Medicare Advantage members do not get these bills).  

So let’s get started.  The bills I will be talking about in these videos are the bills from Medicare.  Medicare calls their bills the “Medicare Summary Notice.”  Samples of these bills are available on the Medicare website.  For the purpose of these videos, we will be using examples that are available for download as of the date of this taping: February 5, 2019.  Everyone who still has Medicare as primary payor and people who have Medicare as secondary payor can expect to receive notices such as these.  Please note that Medicare Advantage members will NOT receive notices like these.  If you have a Medicare Advantage plan and need help understanding your bills, it will be in your best interest to speak with your qualified insurance broker or a member of that company’s customer service team for assistance.

 

 

 

The notice for Medicare Part A shows all the services billed to Medicare for inpatient care in hospitals, skilled nursing facilities, hospice, and home care services.  The notice you receive is going to be a minimum or four pages long.  Let’s look at the first page.

Page 1 is called your “Dashboard.”  At the top left corner of the page is the Medicare/HHS logo.  Directly under that in a gray box under your address is your information.  You can expect most of your Medicare number to be hidden, however the last 4 digits of the number should be displayed to help identify the notice as yours.  Under the Medicare number is the print date of the notice.  And under that is the dates of service this notice covers.  Please pay attention to that date range.  It is possible you are looking at claims from provider visits that are further back in the past than you may be expecting.

 Under the gray box is your deductible status.  Please do not get the deductibles for Medicare Part A and Part B confused.  A deductible period for part A can happen multiple times in a year and is significantly higher than the Medicare Part B deductible.  They are two separate amounts which do not combine with one another.  A notice showing just Part A will only discuss the Medicare Part A deductible.  This section will show how much of your deductible has been met or is now met for Part A.  Remember the definition of deductible: this is the amount that someone must pay before Medicare pays its share.  Usually, the payor of the deductible is either you or an insurance policy such as a Medicare supplement.

 On the top box on the right hand column of the summary notice is the total you may be billed section.  This will tell you if Medicare approved all claims in the notice.  Please note it is not uncommon for Medicare to reject certain claims as many services are billed in groups and certain rejected claims are not your responsibility to pay.  This will be covered in the next couple pages.  In the small gray box under that is the total amount which may be billed.  This is the amount of the bill not paid by Medicare, and will either be paid by your, or a third party such as private insurance.

Under that, the last section of the dashboard is a list of facilities you went to.  If you went to multiple facilities covered in the dates you are seeing this claim notice for, please check to make sure all the places you went are listed on the form.  If one is missing, there may be additional claims forthcoming.  If you see a location unfamiliar to you, contact that facility for more information.

 Let’s go on to page two.  Most people ignore this as a “fine print” page.  However some of that fine print may be important to you.  Let’s break it down.

 At the top left corner is a big gray box.  It has frequently asked questions. 

 Under that are instructions on how to report Medicare fraud if you suspect any.  Medicare fraud and abuse are significant factors in cost increases.  If you suspect any Medicare fraud, please contact Medicare and let them know.

 The section under that is whom to call if you have questions.  The last line also includes the number for your state’s senior health insurance program.  Of course, if you have medicare-related health insurance, you should also be able to reach out to your agent or broker for help in taking first steps.

 Going to the top right hand corner of the screen, you come to the description of benefit periods.  This is especially important under the Part A notice, because many people are unaware how Part A’s benefit period works.  It is not an annual period.

 The last section on page two is a message from Medicare.  Medicare typically has two or three advisories on each notice for you each time you get one.

Let’s move on to page three.  This is the meat of the notice.  Your claims.  The very top of the page shows what type of claim it is, and it can be either inpatient or outpatient.

Under that are definitions.  Very important to know for understanding what you are about to read.

Next is the claim itself.  It will begin with the date you were in the facility and which facility you were at.  Under that will be the line item for each benefit period at that facility.  The immediate next column will show how many days you used in that facility.  Next will be whether the claim was approved or denied

 Next column over is non-covered charges.  If a claim was denied or only partially approved, the amount not covered in the approval will show up there.  Not all non-covered charges are your responsibility to pay, but some are.  Pay attention to the footnotes for more info.  The next column is the amount Medicare paid.  This is not always the full amount.  See footnotes for more info. 

 Next is the column of the total amount you may be billed.  This amount may be billed to you, or if you have a secondary payor, them.  It is highlighted in bold to make it stand out.

 And next is, in our opinion, the most important part.  The notes.  Let’s talk a bit about the notes column.  In our opinion, the footnotes are the most important part of the notice.  Medicare is required to give an explanation for every claim that is denied, every charge you may be incurring.  Each charge usually has one footnote, sometimes even more than that.  It is important to read these notes, as they can sometimes tell you that a claim was denied but you are NOT responsible for paying the charge.  Sometimes a claim is your responsibility because it is part of the deductible amount and it will tell you in the notes.  And sometimes the notes will say that they paid their share and what you see there is what your responsibility will be, or that of a second payor.  The notes are the place where real detective work begins.

 Let’s move on to the last page.  In this example, the notice is only 4 pages long, in the real world, page 3 extends as long as there are claims to report.  As we move to the last page, we get to the part of how to handle denied claims.  We want to caution people on this.  Before filling out an appeal, we encourage a little investigation.  Sometimes, appeals are unnecessary as a little correction of the claim from the facility’s end can fix the problem.  Whenever in doubt, talk with someone knowledgeable about these matters before beginning the appeal process unless there is a time sensitive emergency.

 Regardless, lets analyze the last page.  We begin at the top, where you receive instructions on what to do if a claim was denied: how to go about getting more information to see if you have a potential problem.

 Below that is what to do if you wish to file an appeal.  Medicare gives you 120 days to file one.  They also list when your appeal must be received. 

 Under that is whom to contact should you need assistance in filing your appeal.

 Lastly, on the right column is the appeal form.  It lists the steps to take to go about filing the appeal.  To file it, you circle the claims in prior pages you have a disagreement with.  Then you write out a statement to them why you feel the decision was made incorrectly by Medicare.  Remembering to include any documentation or other proof you have along with the statement.  Then you fill out your name or that of the person helping to file the appeal.  Be sure to make copies of everything.  Mail in the originals to the address on the note, but keep the copies in case the originals do not make it to their destination, and to refer back to later should that be necessary.  Remember, we strongly advise professional advice and assistance before taking the step of filing for a claim appeal.

 And that’s about all there is to the Medicare part A summary notice.

 

The Medicare Part B Summary Notice

 

Page 1 is called your “Dashboard.”  At the top left corner of the page is the Medicare/HHS logo and confirmation that you are receiving a notice for benefits paid under Medicare Part B.  Directly under that is your mailing address and then in a gray box under that is your information.  You can expect most of your Medicare number to be hidden, however the last 4 digits of the number should be displayed to help identify the notice as yours.  Under the Medicare number is the print date of the notice.  And under that is the dates of service this notice covers.  Please pay attention to that date range.  It is possible you are looking at claims from provider visits that are further back in the past than you may be expecting.

Under the gray box is your deductible status. The deductible for Medicare part B is a once a year annual deductible, not a per period deductible like Medicare part A.  Once you have met this amount for the year, it will not return until the following January.  This section will show how much of your deductible has been met or is now met for Part B.  Remember the definition of deductible: this is the amount that someone must pay before Medicare pays its share.  Usually, the payor of the deductible is either you or an insurance policy such as a Medicare supplement.

On the top box on the right hand column of the notice is a quick overview of what’s inside.  This will tell you if Medicare approved all claims in the notice.  Please note it is not uncommon for Medicare to reject certain claims as many services are billed in groups and certain rejected claims are not your responsibility to pay.  This will be covered in the next couple pages.  In the small gray box under that is the total amount which may be billed.  This is the amount of the bill not paid by Medicare, and will either be paid by your, or a third party such as private insurance.

Under that, the last section of the dashboard is a list of providers you saw.  If you went to multiple providers covered in the dates you are seeing this claim notice for, please check to make sure all the places you went are listed on the form.  If one is missing, there may be additional claims forthcoming.  If you see someone unfamiliar to you, contact the provider’s office listed for more information. 

Let’s go on to page two.  Most people ignore this as a “fine print” page.  It is very similar to the page two on the Part A notice.  Let’s break it down. 

At the top left corner is a big gray box.  It has frequently asked questions.  Basic information you need to know about what you are reading. 

Under that are instructions on how to report Medicare fraud if you suspect any.  Medicare fraud and abuse are significant factors in cost increases.  If you suspect any Medicare fraud, please contact Medicare and let them know.

The section under that is whom to call if you have questions.  The last line also includes the number for your state’s senior health insurance program.  Of course, if you have medicare-related health insurance, you should also be able to reach out to your agent or broker for help in taking first steps.

Going to the top right hand corner of the screen, you see a notice describing preventative services and how to find out which services might be available to you.

The last section on page two is a message from Medicare.  Medicare typically has two or three advisories on each notice for you each time you get one.

Let’s move on to page three.  This is the meat of the notice.  Your claims.  The very top of the page shows what type of claim it is, whether it is assigned or unassigned.  An assigned claim means a doctor has agreed to accept Medicare’s charges in full and may not bill you the difference.  Please be aware this is not the same as the typical 20% amount owed.  That may still be charged as it is part of the assignment-agreed upon amount.

Under the top section are definitions.  Very important to know for understanding what you are about to read.  That is taken by the upper part of the page.

Next  down is the claim itself.  It will begin with the date you saw the provider and the provider’s name and office.  Under that will be the line item for each service. 

Working to the right from each line item, right after the description of the service provided and the billing code, you get a simple yes/no answer to whether or not a service had been approved.  Please do not panic yet if you see a “no.”  There may be more to the claim than what you are seeing right there

To the right of the approval column is the amount the provider charged Medicare.  And to the right of that column is the amount Medicare approved.  When a provider has agreed to accept Medicare assignment, they have agreed to take the Medicare approved amount and disregard the original billed amount, if those two numbers are not the same.

The next column from that is the amount Medicare paid.  Since this is a Medicare Part B claim, this number should be 80% of the number in the Medicare approved amount column.  However, remember that not all Medicare Part B claims are paid at 80/20. 

Next is the column of the total amount you may be billed.  This amount may be billed to you, or if you have a secondary payor, them.  It is highlighted in bold to make it stand out.

And the last column is, just as in part A, the most important part.  The notes.  Let’s talk a bit about the notes column.  Medicare is required to give an explanation for every claim that is denied, every charge you may be incurring.  Most charges usually have one footnote, sometimes even more than one.  If a charge is denied, there’s always a reason given.  It is important to read these notes, as they can sometimes tell you that a claim was denied but you are NOT responsible for paying the charge.  Sometimes a claim is your responsibility because it is part of the deductible amount and it will tell you in the notes.  And sometimes the notes will say that they paid their share and what you see there is what your responsibility will be, or that of a second payor.  Very frequently, if you are a Medicare Supplement insurance policyholder, the notes will say they sent the remainder of the claim to your supplement for payment.  To see the results of that payment, please check with the statement of benefits from your supplement carrier.  Whenever my clients come to me with a problem stemming from a Medicare claim, the notes section is the place where we typically find our next steps. 

Let’s move on to the last page.  In this example, the notice is only 4 pages long, in the real world, page 3 extends as long as there are claims to report.  As we move to the last page, we get to the part of how to handle denied claims.  We want to caution people on this.  Before filling out an appeal, we encourage a little investigation.  Sometimes, appeals are unnecessary as a little correction of the claim from the provider’s billing office side of things can fix or shed light on a lot of the problems.  Whenever in doubt, talk with someone knowledgeable about these matters before beginning the appeal process unless there is a time sensitive emergency.

Regardless, lets analyze the last page.  We begin at the top, where you receive instructions on what to do if a claim was denied: how to go about getting more information to see if you have a potential problem.

Below that is what to do if you wish to file an appeal.  Medicare gives you 120 days to file one.  They also list when your appeal must be received. 

Under that is whom to contact should you need assistance in filing your appeal.

Lastly, on the right column is the appeal form.  It lists the steps to take to go about filing the appeal.  To file it, you circle the claims in prior pages you have a disagreement with.  Then you write out a statement to them why you feel the decision was made incorrectly by Medicare.  Remembering to include any documentation or other proof you have along with the statement.  Then you fill out your name or that of the person helping to file the appeal.  Be sure to make copies of everything.  Mail in the originals to the address on the note, but keep the copies in case the originals do not make it to their destination, and to refer back to later should that be necessary.  Remember, we strongly advise professional advice and assistance before taking the step of filing for a claim appeal.

 

The Medicare Durable Medical Equipment Summary Notice

 

This is the third and final part of our series on how to read a bill (officially called by Medicare, the “Medicare Summary Notice.”)  In this section, we are going to look at the bill for Medicare Part B’s Durable Medical Equipment (called a DME) charges and payments.  For those who have already seen our Part A & B videos, the information will be very similar to them.  Since most DME’s fall under part B, the notice will be almost identical to the Part B information given in that video.  I will just mention some highlights of the similarities between the Part B notices and this one.  For a more thorough explanation, watch the Part B video.

 Let’s begin.  We’ll start with page one.

 Page one is your “dashboard” and is identical to the Part B dashboard.  The one difference between this dashboard and the standard B dashboard is on the right side, where it lists suppliers you received equipment from rather than providers who treated you medically.  Everything else here is the same as Part B.

Moving to page two, it is again, the same as a Medicare Part B summary notice.  No significant changes between them.

 As we get to page 3, the heart of the claim, we start seeing some subtle differences.  First, as we look at the top, you have assigned and unassigned notices.  An assigned claim means a supplier has agreed to accept Medicare’s charges in full and may not bill you the difference.  Please be aware this is not the same as the typical 20% amount owed.  That may still be charged as it is part of the assignment-agreed upon amount.

Below that are definitions.  It is important to know definitions to understand what you are about to read.

Next  down is the claim itself.  It will begin with the date you ordered your supplies and who the suppliers were.  Under that will be the line item for each service. 

Working to the right from each line item, right after the description of the service provided or piece of equipment ordered and the billing code, you get a simple yes/no answer to whether or not a service had been approved.  Please do not panic yet if you see a “no.”  There may be more to the claim than what you are seeing right there

To the right of the approval column is the amount the supplier charged Medicare.  And to the right of that column is the amount Medicare approved.  When a supplier has agreed to accept Medicare assignment, they have agreed to take the Medicare approved amount and disregard the original billed amount, if those two numbers are not the same.

The next column from that is the amount Medicare paid.  Since this is a DME claim, this number not always 80% of the approved amount.   

Next is the column of the total amount you may be billed.  This amount may be billed to you, or if you have a secondary payor, them.  It is highlighted in bold to make it stand out.

And the last column is, just as in the other two parts, the most important part.  The notes.  Medicare is required to give an explanation for every claim that is denied, every charge you may be incurring.  Most charges usually have one footnote, sometimes even more than one.  If a charge is denied, there’s always a reason given.  It is important to read these notes, as they can sometimes tell you that a claim was denied but you are NOT responsible for paying the charge.  Sometimes a claim is your responsibility because it is part of the deductible amount and it will tell you in the notes.  And sometimes the notes will say that they paid their share and what you see there is what your responsibility will be, or that of a second payor.  Very frequently, if you are a Medicare Supplement insurance policyholder, the notes will say they sent the remainder of the claim to your supplement for payment.  To see the results of that payment, please check with the statement of benefits from your supplement carrier.  Whenever my clients come to me with a problem stemming from a Medicare claim, the notes section is the place where we typically find our next steps.

Let’s move on to the last page.  In this example, the notice is only 4 pages long, in the real world, page 3 extends as long as there are claims to report.  As we move to the last page, we get to the part of how to handle denied claims.  We want to caution people on this.  Before filling out an appeal, we encourage a little investigation.  Sometimes, appeals are unnecessary as a little correction of the claim from the supplier’s billing office side of things can fix or shed light on a lot of the problems.  Whenever in doubt, talk with someone knowledgeable about these matters before beginning the appeal process unless there is a time sensitive emergency.

Regardless, lets analyze the last page.  We begin at the top, where you receive instructions on what to do if a claim was denied: how to go about getting more information to see if you have a potential problem.

Below that is what to do if you wish to file an appeal.  Medicare gives you 120 days to file one.  They also list when your appeal must be received. 

Under that is whom to contact should you need assistance in filing your appeal.

Lastly, on the right column is the appeal form.  It lists the steps to take to go about filing the appeal.  To file it, you circle the claims in prior pages you have a disagreement with.  Then you write out a statement to them why you feel the decision was made incorrectly by Medicare.  Remembering to include any documentation or other proof you have along with the statement.  Then you fill out your name or that of the person helping to file the appeal.  Be sure to make copies of everything.  Mail in the originals to the address on the note, but keep the copies in case the originals do not make it to their destination, and to refer back to later should that be necessary.  Remember, we strongly advise professional advice and assistance before taking the step of filing for a claim appeal.

And that ends the last part of our series on how to read a bill, or “Medicare Summary Notice.”  We hope you found this information useful.  Please be sure to check out our other videos in this three part series about how to read a bill.  And also our youtube channel where we have little videos answering common Medicare questions and another series going over timely medicare news. 

After you’ve got a baseline understanding of what you need and you need help with your next steps, we encourage you to reach out to a knowledgeable insurance advisor.  And if you live in Ohio, West Virginia, or Kentucky, reach out to us and we are happy to walk you through your next steps.

 

Finally, here is the link to Medicare's description page on their Summary Notices, where you can read their descriptions and download copies of the latest models of the forms.

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