WHAT HOSPITAL BENEFITS AM I ENTITLED TO
What is a Medicare Assignment? If the provider does not accept Assignment, will I have to pay the entire original charge?
What are the advantages of Assignment? Does the Ban on Balance Billing apply to all Medicare providers?
How does Assignment work? What should I do if I disagree with a claim decision?
What if my provider does not accept Assignment? Should I have legal representation when appealing a claim?
Who is responsible for submitting my claims to Medicare? Is it worth my time and effort to appeal an unfavorable Medicare claim?
If you are enrolled in Medicare, here's a tip that might help you save money:
When you require medical treatment and services, ask your provider if he or she accepts Mecdicare Assignment



What is a Medicare Assignment?
When you assign your claim to a provider, you are telling the provider to receive payment directly from Medicare. Some providers, called "participation providers," have agreed to submit all their Medicare claims on an assigned basis. Non-participating providers, called "Medicare Providers," may choose whether to accept assignment on each individual claim.


What are the advantages of Assignment?
Then most important advantage of assignment is that the provider who accepts Medicare assignment agrees to accept Medicare's "approved amount" as full payment for the covered services.
A provider who accepts assignment may not require you to pay up front for the full cost of the services you receive. Further, in the event that Medicare does not approve the claim, you may be protected from liability if you provider accepted assignment.


How does Assignment work?
The provider submits the claim to Medicare and Medicare pays 80% of its approved charge to the provider. You may be billed only for the remaining 20% and any unmet portion of your yearly Medicare Part B deductible.
-Example-
You receive outpatient physical therapy serviced that cost $125. The physical therapist accepts assignment. Medicare approves the claim, but Medicare's approved rate is $100, rather that $125. Medicare will pay the therapist 80% of the approved rate, or $80/ You may be billed only for the remaining 20%, or $20. The therapist must "write off" the $25 difference between the original charge and the Medicare approved rate.


What if my provider does not accept Assignment?
If your provider will not accept assignment, you must pay the provider directly for his or her services and wait for Medicare to send you reimbursement, and you may have to pay the provider the entire original charge.




Your Rights to Medicare Assignment...
Who is responsible for submitting my claims to Medicare?
In the past, either you or the provider Could submit claims paperwork to Medicare with an unassigned claim. Providers are now required to file all beneficiary medical claims, whether or not they take assignment.


If the provider does not accept Assignment, will I have to pay the entire original charge?
Ordinarily, if a provider does not accept assignment, he or she can demand payment of the entire original charge. However, in Massachusetts there is a law protecting Medicare beneficiaries who receive services from physicians licensed by the Massachusetts Board of Registration in Medicine. As long as you are covered by Medicare, your physician can only charge you the rate Medicare allows for the service, whether he or she accepts assignment or not. This law is called the Ban on Balance Billing.

-Example-
You are covered by Medicare and are treated by a doctor. The doctor charges you $150:

If your physician accepts assignment, he or she may bill Medicare before asking you to pay any of the bill.

If your doctor does not accept assignment, you may have to pay at the time of the visit.

No matter what the case, the doctor's clerk must send your claim to Medicare.

Medicare will process the claim, and send you an "Explanation of Medicare Benefits" stating the approved rate for the treatment you received. The approved rate may be lower than the cost of your treatment.

No matter what the original cost, your physician cannot charge more than the Medicare approved rate.

Medicare will then pay 80% of the approved rate and you must pay the remaining 20%.

So if your treatment costs $150 and the approved rate is $100, Medicare will then make payment for 80% of the approved charge, or $80.

If your doctor accepted assignment on your claim, Medicare will pay your physician directly and you must pay the remaining 20%, or $20.

If your doctor did not accept assignment, and you already paid your physician $150, Medicare will pay you the $80. You would now be entitled to a refund from your physician for $50.

If you think you should get a refund then it is up to you to bring this to your doctor's attention and request a refund or credit.


Does the Ban on Balance Billing apply to all Medicare providers?
No. This limit on billing Medicare patients applies to physician services only . Other Medicare Part B providers are only limited to accepting Medicare's approved rate of charge if they accept assignment.


What should I do if I disagree with a claim decision?

You should call both your medical provider and the Medicare carrier referred to in the Explanation of Medicare Benefits with questions about your Medicare claim if you are unhappy with a coverage determination. If you remain dissatisfied with the Medicare decision, you may appeal your claim decision. Appeals may be filed whether or not your claim was assigned. The claim will include instructions for appealing a Medicare decision.


Should I have legal representation when appealing a claim?

It is very helpful to have legal representation when appealing denials of Medicare coverage for services because the laws regarding Medicare are very specific and sometimes confusing. A legal representative will review the services received to be sure that you qualify for Medicare coverage.


Is it worth my time and effort to appeal an unfavorable Medicare claim?
You should appeal if you received services that you believe Medicare should have covered. You have nothing to lose; appealing will not jeopardize your Medicare benefits. Contact your local MAP office if you have questions about your Medicare claims.

A self-help brochure published by the
Massachusetts Medicare Advocacy Project (MAP) - July 1995
Reprinted with permission

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