Q: Some Medicare and health maintenance organization (HMO) providers have asked patients to sign forms stating that the providers have no contracts with Medicare or the HMO, that the patient is the one who has the contract, that the patient is responsible for paying the provider and that the provider will bill Medicare or the HMO directly if the patient will sign a form allowing this. The form states that the patient, not the HMO or Medicare, is responsible for payment. The provider will then bill the patient for the difference between what they received from the HMO or Medicare.
I asked my HMO about this. They claim that the contract is between the provider and the HMO, that the patient cannot see the contract because they are not a party to it and that the contract states that the provider must accept the HMO payment as full payment. When I asked my HMO what to do for the providers who did not agree to this, they told me to find a different provider.
A: Providers enter into contracts with Medicare and health plans that establish how much the provider is going to be paid for specific services. Most contracts also establish how much the provider can receive from the patient.
The difference between what the provider has contracted to receive and the amount he or she would like to be paid is the “balance” of the bill, or balance billing. Under most contracts, balance billing is prohibited or capped. Under Medicare rules, a provider treating a Medicare patient, but not accepting the Medicare approved amount as payment, can charge up to 15 percent more than Medicare’s approved amount. The patient must pay 20 percent of the Medicare approved amount plus all of the additional charges, up to an additional 15 percent of the Medicare approved amount. If a provider is not part of an HMO plan network or not participating with Medicare, the provider can charge the patient any amount. Co-payments are much lower when you use a provider who accepts the Medicare-approved payment or a provider who is part the private plan network.
Q: I just received a postcard in the mail today to fill out survey. It says if I fill out the survey it will give them information that will help us become eligible for Medicare. They will then forward us a Planning for Medicare booklet.
A: It is very easy to find out if you are eligible for Medicare. Just go to Medicare.gov or get a copy of the free Medicare and You. You can download it from Medicare.gov, read a copy at your public library or get a copy from your local Social Security office.
The postcard you received is most likely from an insurance company that wants to find out if you are interested in a Medicare Advantage plan or Part D Prescription Drug plan. If you aren’t interested in getting marketing material, don’t fill out the survey.
Q: Somebody came to my door wanting to sell me a Medicare supplemental policy that he said was required by the new law. When he asked for my Medicare number I told him to get lost. Did I do the right thing?
A: Yes, you sure did. Medicare never sends representatives to go door-to-door. Nor will it try to sell you a supplemental policy. If you think someone is trying to scam you or steal your Medicare number, call Medicare at 800-633-4227.
Q: I assume there are sometimes legitimate phone calls to consumers from health insurance agents and appointment setters.
A: Yes, most heath care providers and insurance agents, as well as all other professionals, are honest. But before you purchase any insurance product or share personal information, be sure to verify any information you receive and carefully compare the details with other similar offerings.
Q: How can you check on a state license?
A: To see if an insurance agent is licensed to sell insurance in your state, contact your state insurance department. You can find contact information in the blue (government) pages of your phone book. You can also go to NAIC.org to find the phone numbers and website for your state insurance department.