When Medicare says you owe $0 but the doctor bills you

This situation happens when Medicare denies a service, the Medicare Summary Notice says the maximum you may owe is $0, and the provider bills you anyway. The notice is not a bill, but it shows the maximum amount Medicare says you may owe the provider.

Start with the $0 amount on the Medicare Summary Notice. Compare the claim, date, service and provider with the office bill. If they match, dispute the office balance before paying more.

An ABN is used in certain Original Medicare situations when a provider expects Medicare to deny payment. A valid ABN can transfer possible financial responsibility to the patient. If no ABN was given, ask Medicare whether the denial reason allowed the provider to bill you anyway. A previous written notice about the same or a similar service can affect that decision.

1. 1.Match the office bill to the Medicare Summary Notice. Confirm the provider, service date and service are the same.
2. 2.Call the billing office. Say the Medicare Summary Notice lists $0 as the maximum you may owe. Ask the office to place the account on hold while it reviews the claim.
3. 3.Send the office a copy of the relevant Medicare Summary Notice page. State that you did not receive or sign an ABN. Ask for a corrected statement showing a zero balance.
4. 4.If the office says the claim was submitted incorrectly, ask it to correct and resubmit the claim. Medicare advises contacting the provider when a denied claim may contain incorrect information.
5. 5.If the office refuses, call 1-800-MEDICARE at 1-800-633-4227. Ask Medicare to confirm your financial responsibility and explain the proper appeal or complaint route. SHIP also provides free Medicare counseling.

Ask the billing office for a refund in writing. Include the Medicare Summary Notice, the provider bill and proof of payment. Federal refund rules apply in certain cases involving physician services denied as not reasonable and necessary, but the rule has exceptions. Ask Medicare or SHIP whether that refund rule applies to your claim if the office refuses.

Not always. A provider that accepts assignment agrees to accept the Medicare approved amount as full payment for covered Part A and Part B services and may charge only the applicable deductible and coinsurance. Ask Medicare to confirm whether the provider accepted assignment for this claim.

Appeal if you disagree with Medicare’s coverage or payment decision. The last page of the Medicare Summary Notice gives instructions for filing an appeal. If you agree with the denial but dispute the provider’s bill, ask Medicare which complaint or billing route applies instead.