It will be on the EOB that is unreadable. LOL, sorry You need to know the HCPCS code and/or CPT code charged by the provider to look it up on the MC site. Most people don't know what HCPCS and CPT codes are. All medical procedures/services have a code for billing to insurance companies. Then a thing called a modifier sometimes comes into play. It is complicated for the lay person to look up the code themselves. The code should be on the EOB. Sorry they don't make it easy. Good luck.

https://www.cms.gov/apps/physician-fee-schedule/overview.aspx 

An Explanations of Benefits is prepared by my private insurance company for any submitted service. The charge goes first to Medicare, then to my insurance company as secondary insurer. Each EOB shows Gross charge, "Discount", how much Medicare paid, how much my insurance paid, what my cost share is and why (copay, co insurance, deductible, etc.) Each service line item is described briefly in plain English. I'm not sure reference to the charge codes is either necessary or useful if you can get what I get.

Medicare monkey business has to do with disreputable providers submitting charges for things they didn't do, either by misclassification or otherwise. If you see that the service description sounds right, I don't think wading in the muck of the detail is going to do anything for you.

Geez,no wonder there are so many stories of fraud. Seems complicated beyond recognition/understanding.

Elmer at this time DH has no supplemental ins., so no EOB that I could use as you explain.

This might help you read the statement. https://www.aarp.org/health/medicare-insurance/info-05-2011/popup-part-b-medicare-summary-notice.html  Does your husbands statement look like this?

I strongly urge everyone on Medicare to create their account on the Medicare website. It's free, easy, and secure. On that site, you can check to see if your doctor accepts the Medicare assignment (meaning s/he cannot bill you for the amount that Medicare doesn't cover). You can also check to see if various procedures are covered by Medicare.

When you sign into your own Medicare account, you will see your claims. They really are very easy to understand. Here is an example, taken from my account.

(I've blurred out any identifying information.) OK, the top part (gray) is an example of what you see when you sign in and see your five most recent claims. You can see that this was at a provider affiliated with a hospital system, that I was an "outpatient," the service date was 06 Nov 2017, and the total amount charged was $410. Medicare approved the full $410, but out of that, Medicare paid $22.89 to the provider. Nothing was applied to my Medicare deductible, and I will not be billed anything.

The lower part of the image is the detail from the claim itself. You can see that the claim is for blood tests. (I had a parathyroidectomy in November, and this was part of the pre-op blood work.) The tests were (1) Comprehensive Chemistry Panel, (2) Bilirubin Level, and (3) Complete Blood Count.

Look at the Payment Summary in the center of the bottom image. The amount with which you would need to be concerned is the Total Amount You May be Billed -- which in this case shows $0.00.

If there had been an amount there, my Anthem Blue Cross supplemental policy would have covered it.

Lindsey look simple to me, but some people have a hard time reading statements/EOB. I am surprised the ICD-10 isn't listed.

Good call, Lindsey. I'm new with having Medicare as primary but I don't bother looking at it since for me, the processing isn't done until my secondary insurer has done its thing.

The billing code is listed on the Medicare Summary Notices (MSNs) I found on my My Medicare page but I'll repeat that unless you have reason to think a mistake was made, if the amount seems reasonable, I think it can be left at that.

Billing codes for procedures and services are nothing new and have long been in use for insurance billings. Unless some of you didn't have medical insurance before getting Medicare coverage.

Lindsay_CA said:

On that site, you can check to see if your doctor accepts the Medicare assignment (meaning s/he cannot bill you for the amount that Medicare doesn't cover).

I thought that if the doctor said he accepts m/c, it meant he charged m/c scheduled fees. If that is the case, then sounds like I shouldn’t be paying these $10 or whatever fees that were getting.

sorry, lindsay but those statements are not easy to read. Plus they tell how much a doc was paid but I have no way of telling if over/under the scheduled rate. From that m/c statement I cannot tell if the $10 additional amt we’ve invoiced are accurate. I have nothing with which to check.

i read my insurance EOB with no problems. And I repeaT, no supplemental insurance so the piddley $10 invoices are a concern to me if I cant verify their accuracy. So far, I haven’t found an easy way to do so. Which is why I’m here.

functionthenlook, you are making things more complicated than they need to be. There is no reason for folks to look up or know the codes. All they need to know is how much they are responsible to pay.

And, by the way, your link leads to a "404 Page Not Found" error. Way to go.

I really don't look at our EOBs. Should though. My husband opens the mail and only it it puzzles him does he ask me to look at it. 95% EOBs are for my husband anyway. I only have had one time a provider billed for services not rendered. And that was a dentist.

Bossy -- this is a copy/paste from what I posted on 04 Oct 2017:

~*~*~*~*~

In the "world of Medicare," there are doctors who accept the Medicare assignment all of the time and they are referred to as "participating providers." There are other doctors who accept the Medicare assignment only for certain patients and/or for certain procedures. Folks also need to know that Medicare determines what amount they are going to pay for each and every procedure, whether it's a simple office visit or complicated surgery. Medicare will pay 80% of that predetermined amount. The patient is then responsible for paying the other 20% of that predetermined amount. The total the doctor will receive is 100% of that pittance amount that Medicare has predetermined. That is the "Medicare Assignment." (If the patient has a Medicare Supplement policy, aka a Medigap policy, that policy generally will pay the patient's 20%. I say "generally," because there are a couple of Medicare Supplement policies that either make you pay a specific amount as a deductible before the policy will pick up and pay, or else they still have the patient pay an office-visit copay. For example, ChiSue has posted before that she and her husband have a high-deductible Medicare Supplement policy, so they have to pay something like $2,500 before their Supplement policy will pay anything.)

There are also doctors who are known as nonparticipating providers. They see and treat Medicare patients and will bill Medicare, but they do not accept the Medicare-approved fee as their full fee. However, this does not mean that they can bill you a sky-high amount. Medicare has a limiting charge which, as the name implies, limits the amount a nonparticipating provider can charge a patient.

As I stated before, Medicare has a predetermined amount that it will pay, and then it pays 80% of that amount. When a nonparticipating provider submits a bill to Medicare, Medicare lowers the predetermined approved amount to 95% of the approved predetermined amount for participating providers. It then pays 80% of that lower amount. Medicare allows the provider to charge the patient 115% of the lowered (95%) fee. The math works out to an end result of the patient being responsible for an extra 9.25% of the Medicare approved fee.

There are other providers who have absolutely nothing at all to do with Medicare. They will not bill Medicare for you, and if you submit a bill to Medicare yourself, Medicare will not pay. Those doctors are free to charge you whatever amount they want, and you are responsible to pay it.

~*~*~*~*~

OK, back to present day...

It doesn't really matter what amount the doctor bills to Medicare. If the doctor accepts Medicare assignment, he cannot charge you anything that Medicare doesn't pay, other than the 20% of what Medicare allows as the fee. If you have supplemental insurance, it will pick up the difference, depending on your supplemental policy coverage.

When I said, "... you can check to see if your doctor accepts the Medicare assignment (meaning s/he cannot bill you for the amount that Medicare doesn't cover)" I meant that if the doctor submits a bill for $22,000 and Medicare allows only $400, the doctor cannot bill you for the $21,600 that Medicare doesn't cover. If you don't have a supplemental policy, Medicare will pay their $320, and you will be responsible for $80. But that will be clearly shown on the claim form on the line Total Amount You May be Billed.

Ok, where do I find, per your example, the M/C allowed rate? Getting billed 21k for a $400 procedure would be glaringly obvious wrong, but what if Dr billed me $100? I would like to look up the approved rate and, with simple math determine my share (w/no supplemental insurance). I’d like to have a way of double checking that bill s/b $80 and not $100 (this could be a code error, a typo, whatever). But since it affects MY pocketbook, I want to check. I appreciate your taking time to explain. I may be slow but I promise I’m reading as carefully as I can.

Linsey It was from AARP. No need to repost the website it was the same as yours. That is why insurance fraud can happen. People are only concerned what the insurance paid for and how much they owe.

Bossyvossy, A doctor who accepts the MC fee schedule can charge anything he wants for his service. The fee schedule is what MC will only cover for a service and the doctor accepts that fee. MC only pay 80% of their fee schedule amount to the doctor and you still owe the 20%. You just want to make sure your doctor is a participating provider. Most doctors are participating providers. Linsey's example is for diagnostic laboratory services and the 80/20 does not apply. Providers payments are the 80/20. If you look at Linsey's example above the "Amount Charged" is what your doctor billed MC. The "Medicare Approved" column is the max amount MC will pay for the service. The 80/20 applies to the "Medicare Approved" amount, not the "Amount Charged".

When there were minors in the household, I was in charge of insurance. I can safely say that 80% of the time there was a discrepancy of some sort. But armed w/EOB and a phone I was always able to resolve discrepancy (or understand reason for discrepancy).

With hubby’s medicare, I’m feeling pretty clueless. I haven’t yet learned how to reconcile invoices and m/c version of EOB

Btw, I’m using my phone so the statement is unreadable. I will look from my laptop tomorrow.

Bossyvossy on Lindsey's example the CPT is 80053 for the first blood test. You really don't need to look up what the code was for since it is listed with the code. In her case she had a CBC drawn. Good for you checking your pocketbook. If you want to know the Medicare approved amount go to the MC fee schedule link I posted above.

I will ck it out. Thank you so much for your help

Function, when I click on link it says error, page not found. AARP link also not working.

I know this isn't what you are asking, but since you have insurance can your husband also be added to yours? I know some will not let you. It can be used as a supplement. My husband is on my insurance and he will start part B in June. I am having him take the MC B because of his multi medical problems. My insurance will cover the 20% and everything will be covered 100% (will not have to pay any copays or coinsurance, yea), plus they reimburse me $600 dollars a year on my premium.

I be dang it doesn't link. OK go to (copy and paste) www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ 

Then on the left had side click on " physician fee schedule look up tool", then click medicare "physician fee schedule". Now labs, surgical procedure, therapies, etc are on a different fee schedule.

Lindsey copy and paste https://www.aarp.org/health/medicare-insurance/info-05-2011/popup-part-b-medicare-summary-notice.html  and it will work

Neither of your last two links work.

You have to copy and paste. It must have to do something with Houzz that it will not link.

Function, I do not need to look at anything on the link you provided, whether it is clicked on or copied and pasted. I am extremely knowledgeable about health insurance billing and Medicare. Also, please spell my name correctly when referring to me.

Function wrote, "Linsey's [sic] example is for diagnostic laboratory services and the 80/20 does not apply. Providers payments are the 80/20." WRONG. A laboratory IS a provider.

Labs charges are not the same as a physician charges. If it is done in the physician's office he/she receives payment for the draw. The other is the lab fee for the testing of blood urine, etc.

Please don't confuse the lay people on this site. Lay people associate a provider as a physician not a lab facility or for testing. Insurance is confusing enough for a lot of people without complicating it more for them. And besides this has nothing to do with bossyvossey question on how to read a MC EOB, look up a fee schedule and assess if she was charged correctly.

Sorry if I misspelled your name somewhere above. I am not known for my typing skills. Who are you credentialed through AAPC or AHIMA?

Bossyvossy -- Here is a screen shot compilation from Medicare for another EOB of mine:

In November 2017, I underwent a parathyroidectomy at the Ronald Reagan UCLA Medical Center (diagnosis - primary hyperparathyroidism). Even though I spent one night in the hospital, it was considered an outpatient procedure.

As you can see from the above screenshot, the total amount charged was $22,575.31. Medicare disallowed $1,620. The Medicare approved amount is $20,955.31. Medicare paid $3,776.15 to UCLA.

The disallowed $1,620 was for intraoperative lab testing for my parathyroid hormone level. When one or more of the four parathyroid glands "go rogue," it/they put out too much parathyroid hormone. So, during surgery to remove one (or more) of the glands, blood is drawn and tested to ensure the hormone level has dropped, thus ensuring the correct gland has been removed. I don't know why Medicare disallowed this amount (it was for multiple tests during the course of the surgery), but I'm guessing that perhaps Medicare feels that the testing is such a standard part of the surgery that it should be (or is) included in the surgical fee. At any rate, after my supplemental policy kicked in, I was responsible for $0.00.

OK, here's an easier example. Before the surgery, I was seen in the doctor's office as a new patient (remember, I live near Sacramento, and traveled to Los Angeles for this surgery). Here is the Medicare EOB:

The total amount charged (billed to Medicare) is $1,085.00. The amount approved by Medicare is $153.60. The amount that Medicare paid to the doctor's office is $120.42. Then (and this is the important part), it says "Total Amount You May be Billed" is $30.72.

Now, look right above where it says "Payment Summary." It says, "You are responsible for $30.72 either directly or through another insurance plan."

So, the EOB form is very clear on the amount for which you may be responsible.

I do have a supplemental policy through my State retirement, and this is the EOB from that policy:

This EOB shows that my supplemental policy paid the $30.72 that Medicare didn't pay. So, out of a total amount billed for this visit of $1,085, Medicare and Blue Cross paid a combined $151.14, and I was responsible for $0.00.

Even without a supplemental policy, the Medicare EOB is extremely clear and easy to understand.

Now, bear in mind that this Medicare EOB doesn't look exactly like the printed EOB that arrives via the US Post Office. That's why you should create a MyMedicare.Gov account and look at the EOBs online.

Lindsay and Function, you are PRECIOUS people for being so thorough W/explanations. I will look at this later and report back. Thank you so very very much!

Lindsey & Function: I spent an hour reviewing DH’s m/c statements and found the data I needed to reconcile statements vs. invoices. I fear no more!

but I have a final question: where would it make sense to file paid medical invoices?

DH created a paper file for his m/c statements. Every year I create a medical file for that year. Don’t want to look in two places. I feel a ‘medical file’ is a better historical record but I’d like to hear your suggestions for optimal organization.

how long do you keep m/c statements? I keep medical files about 5 years or when I need to make space in cabinet, whichever happens first.

i can’t thank you enough for your patient assistance.

If you have Medicare Advantage, do you still need to check the Medicare site? Or just the website for the Advantage coverage?

bossyvossy, are you taking itemized deductions for medical expenses? If yes, keep them for 3 years after you've filed your return. If not, there's probably no need to keep these statements at all. They're available online for a few years anyway, at the My Medicare site.

Some years we itemize. Some we don’t do I’ll keep them accordingly.

Yes, DH and I each pay under $100 in premiums per month for a high deductible Plan F supplementary policy. (Supplementary to our Part B Medicare insurance.) We've saved thousands in premiums over buying the same comprehensive Plan F policy without a deductible. We take a manageable risk of up to $2200 each per year, while being protected against anything over that amount. Only once did one of us approach paying that entire deductible. The rest of the time, the 20% of Medicare allowed costs I have paid was under $300 in a year. DH's out of pocket was under $100.

We are covered against catastrophic medical expenses and are willing to take the $2200 risk. For example, I have paid less than $1200 a year in premiums, plus $300 out of pocket one year. That's $1500/year. If we had a non-deductible Plan F supplementary, the plan would pay everything Medicare didn't, and I'd pay a premium of $2500/year. (Do you see the $1000 savings?)

When DH's company paid our Medicare supplement it was the equivalent of a Plan F. I 'filed' provider bills in the wastebasket because I knew we were not liable for anything out of pocket. That was *free* and easy, and the benefit stopped. We balked at $5000/year for two non-deductible Plan F supplementaries.

I think many people just starting Medicare (age 65) are well enough physically and financially to get total coverage with a $2200 deductible (limited risk). The insurance companies use scare tactics about huge out of pocket costs, yet, as I said, my out of pocket only once met the deductible, while totaling under $300 most years.

Yes, providers bill exorbitant amounts (Example: $1000), but a provider who accepts Medicare assignment will accept the negotiated amount (Maybe $100). Medicare pays them $80. You pay them $20. You are not paying 20% of the "sticker price" -- although that's what the insurance industry would have you believe.

I pay no provider bill before 90 days. Usually that is enough time for the whole thing to have been ironed out, and I will have received my Medicare statement telling me the amount for which I am responsible.

Never give a hospital your money until the dust has settled. You will spend ages trying to get any over-payment back.

TAX Reminder: Itemize your premiums for Medicare Part B and Part B Supplements, and for Part D, and all medial payments out of pocket. (Dental bills are a biggie for me.) You can add your transportation costs too.

Interesting, ChiSue. On 05 Oct 2017, in another thread about Medicare, you wrote, "DH didn't sign up for a Plan D because he took no prescription meds. Now, though, he has three 'maintenance' meds. Each year he pays a *penalty*, based on how many years he failed to buy Part D coverage. (It's not huge, but it's more than he saved over the years he didn't pay Plan D premiums.)"

My husband and I both have Original Medicare Part A & Part B, and we both have the equivalent of a Plan F supplemental policy with ZERO deductible. Before retirement and before going on Medicare, our health insurance policy was the California State Employees PERSCare PPO plan (Anthem Blue Cross), and when we went on Medicare that policy converted to a PERSCare PPO Medicare Supplement plan (still through Anthem Blue Cross). Although our retirement income is over the threshold to pay just the standard Medicare premiums (so we have to pay the additional IRMAA premium), the State of California reimburses us for the entire premium (which includes reimbursement for the IRMAA premium) as part of our retirement health benefit. All State of California Employee health insurance policies include coverage for prescription drugs, so we don't have a separate Medicare Plan D. However, we do have to pay the Part D IRMAA. State law does not provide for the reimbursement of Part D premiums, so the only amount we are responsible for is the $13 per month each for the Part D IRMAA (total of $312 annually). We pay up to $10 for a 90-day supply of meds, and less if it's a fewer-day supply or a really inexpensive med (for example, I recently paid $0.21 for a 90-day supply of Lasix).

As shown by some of my posts earlier in this thread, I had surgery in November. And, four days ago I had an emergency cardiac procedure - I now have a stent in my right coronary artery (which was 99% blocked before the procedure). I'm also on a new maintenance med (Effient -- a blood thinner), so I am very happy to have a supplemental policy, and very happy to not have a high deductible.

Lindsey -- We were not state employees, so no such generous packages for us!

I posted about our high-deductible hoping to make people see they have options between "No supplemental" and paying thousands on premioums for protection they probably don't need. Insurers' ads infer that a person will have to pay 20% of some hugely inflated bill, not just 20% of the vastly reduced medicare approved amount.

DH's penalty for being late to the Part D party is currently $7/mo. on top of his Part D insurance tab. (Soc. deducts $37 instead of $30.) The advisor at our senior center advised that he not take a Part D way back when, and that was fine. Then Part D became mandatory, and we missed that fact.

Bossyvossy -- if your husband hasn't already set up his MyMedicare account, I urge you/him to do so. You will be able to see, and download to your computer, all of his Medicare EOB forms. And your health insurance company most likely has a site where you can download copies of your EOB forms, too.

What I do for our tax stuff won't necessarily work for everyone else, but it works for us, so I'll throw it out here and you can either adapt it to your own needs or ignore it altogether.

The IRS and the State of California both have fill-in PDF tax forms. In my "Documents Library" I have a folder named Acrobat and within that folder are various folders for Adobe Acrobat files, including our tax forms.

Anyway, within the folder for 2017, I have three folders:

Anything we receive that documents a deduction gets saved to the Deductions folder. Even if it's an e-mail that's received to thank us for a donation, etc., I save a copy of it to that folder. I have a scanner, so I scan documents that are received in the snail mail, and those scans are also saved here. The hard copies get filed in the appropriate place (per my own filing system - I have physical folders for tax documents), but this keeps everything together in one handy location.

Within the Federal and State folders, I have subfolders for the blank forms that I download from the IRS and State of California FTB sites, as well as subfolders for the forms that have been filled in. The electronic copies of instructions for the forms, etc., are kept in the folder with the blank forms.

ChiSue -- does Social Security deduct for your husband's Part D coverage in addition to the penalty for the Part D coverage? Based on the charts that are posted on the Medicare website, the number is off.

2018 Costs for Original Medicare Part B:

2018 Costs for Medicare Part D:

bossyvossy- I would keep them 3 years as Elmer suggested due to tax purposes. Everyone has their own filing system. Some like paperless were you can scan your statement into a file. Or you can just use the old fashion way of putting into a folder in your file cabinet. I would use one folder for your husband and one for you per year. Personally the paper file is faster for me. By the time I fire up my PC and scan in the statement and file it, I can just file it in a paper folder much faster. I don't keep any of my medical records. I just look online with my medical system I use. It contains all the info I need. Appointment past and present, Dx, medications, etc. You pick whatever system of filing that you are comfortable with.

Sail_away- there will be no statement from MC if you have a Medicare Advantage plan. The claim does not go to MC. It only goes to your Advantage plan. Medicare pays the Advantage plan to manage your health care insurance needs.

I agree with chisue, Plan FHD (high deductible) is a good plan for healthy people, it is the broadest supplemental plan with the benefit of low premiums if you don't need it, worse case scenario $2,200 deductible before full coverage. My DH and I are both on it, we just need one that includes Silver Sneakers for us.

In prior years, the medical deduction was limited to the only the expense amount in excess of either 7.5% or 10% of adjusted gross income (I forget which). So people needed to have some combination of low income and relatively high medical expenses to get any deduction for medical costs.

Starting in 2018, the federal standard deduction will be $12K for single filers and $24K for joint returns. With the state tax deduction haircut to $10K in total and the same continuing limit on medical expenses, far fewer people will be itemizing deductions on their federal returns. For many people's state income taxes, changes corresponding to these federal changes have not been made and many may have a federal standard deduction while still itemizing for state taxes.

I expect that when we have regime change in the US, the tax rules will be changed to revert to something closer to what they were before this latest round of nonsensical and deficit bloating changes.

The upshot is that even for those who did deduct medical expenses (and insurance premiums) in prior years, far fewer will do so in the future. If there's no deduction for the current year (which you'll see when your return is prepared), there's no need to keep bills and correspondence beyond when each individual claim has been resolved.

He has an online acct and I now have the password so I can reconcile Acct. however, as Function says, it seems easier to stick/retrieve paper from a file than to fiddle w/laptop. But I can do it either way.

a little o/t, but there are two things to which DH reacts very adversely:

1) act NOW or the whatever deal will be gone forever

2) the fear mongering associated with insurance.

we have the highest deductibles our insurance companies will allow, not b/c of budget constraints but b/c he’s reacting to the manipulation. We might be more conservative later but I can say that up to now, we have paid much less out of pocket vs what we’d have paid in premiums. I fully realize that can change in an instant, but so far, so good. What we don’t pay in premiums we have in interest bearing accounts making money for us, not for the insurance companies. (Silent prayers that it says the same for a looong time)

Hope it isn't for a long time also, but the problem with getting old is not if you fall apart, but when you fall apart. Golden years my ..... lol

My young wife (She is still gainfully employed.) is a CPA and she apparently does not bother to reconcile most of my Medicare stuff. She seems to just scan the page and on rare occasions check an item or two. She seems to be looking for possible duplicates.

Insurance is about prudent risk management. You can look at almost anything that's financial with a victim's attitude and convince yourself someone is trying to take advantage of you. Doing so seems very counterproductive. I hope he can learn to be less skeptical of decisions and situations he faces.

bossy -- Have you refused to buy long term care insurance? (Part of your DH's caution about the "Act now" pitches.)

DH and I took that bait decades ago when John Hancock LTC insurance was hawked through DH's company. After eight years, premiums began to rise more than 'a little'. I noticed stories about Boomers hitting old age; The Old Old; and the rising costs of health care. I thought that premiums would have to rise dramatically, and a lot more people would have to enroll, if our benefits were to be more than a pittance. The question of the company failing to meet its obligations had been in my mind all along.

We decided to cut our losses. When I contacted Hancock, they said that if we paid through Year Ten we'd be eligible for (greatly reduced) benefits. We did that. Every few years we get a letter from Hancock saying they haven't heard from us and will be terminating our policies if we don't reply. We reply.

John Hancock is a pain. Had dealings with them. Oh yea, they sure know how to take your money, but they sure make it hard to collect.

Chisue. It’s simply any seller that uses fear tactics, but of course, ins. People are among the worst. We didn’t go for that.

bossyvossy, your comments that, not in these exact words, you've "saved money by having minimum insurance coverage" doesn't in any way mean that doing so were and have been prudent decisions. It means you've been lucky, not wise. Had you not been so lucky on any one of several counts with your minimum coverages, you might have experienced big financial problems. As before, insurance is about risk management/mitigation and it seems you don't understand it fully. Be happy but don't fool yourself about what's going on.

Elmer, thanks for your observation. I corrected my statement as I meant to say we have the absolute highest deductibles our ins. Cos. willl allow in exchange for lower premiums. Our coverages are prudent. Where we take the risk is by keeping more of our money now and betting 2:1 odds that each coverage term, there won’t be a cash outlay for an event, be it medical, auto, home, title. We are properly covered regardless of whether our deductible share is high or low.