It is important to work with your doctor to ensure you get the best health care possible. This blog covers how you can build an effective relationship with your doctor and make the most of your visits.
Communicate well with your health care provider.
Communication is very important when building relationships with your health care providers and getting the best possible care. To help you communicate with your providers, take the following steps:
Know your rights if a provider does not think your care will be covered.
If you have Original Medicare and your provider believes that Medicare will not pay for a service, they may ask you to sign an Advance Beneficiary Notice (ABN) before you receive that service. The ABN allows you to decide whether to get the care—and pay out of pocket for it—if Medicare denies payment. The notice must list the specific reason why the provider believes Medicare will deny payment.
Providers are not required to give you an ABN for services or items that are never covered by Medicare, such as hearing aids or dental care. Medicare requires providers to only use ABNs on a case-by-case basis. Providers cannot have a blanket ABN policy where they provide an ABN for all services.
If you have a Medicare Advantage Plan, you or your provider should contact your plan and request a formal determination about whether an item or service will be covered. If the plan denies coverage before you receive the service, you should get a Notice of Denial of Medical Coverage within 14 days of requesting the determination (or within 72 hours if you requested an expedited appeal). Follow the appeal instructions on the notice to ask your plan to reconsider its decision not to cover your service or item. Ask your doctor so submit evidence to the plan that you meet the coverage criteria for the item or service and that it is medically necessary.
Contact your State Health Insurance Assistance Program (SHIP) if you want individualized information and counseling about the process. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
Seek a second and third opinion if needed.
A second opinion is when you ask a doctor other than your regular doctor for their view on your symptoms, injury, or illness to help you make an informed decision about treatment options.
Original Medicare covers second opinions if a doctor recommends that you have surgery or a major diagnostic or therapeutic procedure, such as something that would require general anesthetic. Medicare will also cover a third opinion if the first and second opinions are different from each other. The second and third opinions will be covered even if Medicare will not ultimately cover your procedure. Note that Medicare does not cover second and third opinions for excluded services, such as cosmetic surgery.
If you are in a Medicare Advantage Plan, your plan may have different cost and coverage rules for second and third opinions. Contact your plan for more information about costs and restrictions.
Identify billing errors.
Doctors and their billing departments can make errors or honest mistakes when billing. You can spot these errors by reading your Medicare statements and comparing them to your own records. The Senior Medicare Patrol (SMP) offers My Health Care Trackers for this purpose. If something doesn’t seem right, call your provider. For example, you may see that your provider billed Medicare for an office visit on a day when you did not see them. Or, you may see that your provider billed you for a service that seems different than what you actually received. If they made a billing error, they should correct it. If your provider does not fix the error, or if you notice a pattern or errors, contact your local SMP. Your SMP can help you identify Medicare fraud, errors, or abuse, and help you report it to Medicare and the correct authorities.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any other Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
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