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7 Common Medicare Complaints – And How to Resolve Them

While Medicare provides much-needed healthcare coverage, it’d be shocking if beneficiaries had zero complaints. Luckily, most issues are fairly simple to address. In this post, we look at the most common Medicare complaints we see.

1. Medicare Isn’t Paying My Medical Bills

This issue is most common with people who enrolled in Medicare while they still had coverage through an employer (either theirs or their spouse’s). It typically occurs when nobody notifies Medicare that your previous coverage has ended.

When you belong to a group plan through a workplace with more than 20 employees, Medicare is the secondary payer. Whoever manages your benefits should notify Medicare when you leave your employer-sponsored plan. However, this doesn’t always occur in a timely manner, which means Medicare still thinks it pays second, so they send the bill back to your provider, unpaid.

We always recommend you tell Medicare about any changes in coverage. After you notify Medicare that they’re the primary payer, ask your provider to resubmit the claim.

2. I’m Being Asked to Pay My Part B Deductible Twice

In a perfect world, all healthcare providers have a complete understanding of the Medicare billing process – and follow it.

When you have Medicare, your provider is supposed to bill Medicare first – even if you haven’t paid your deductible yet. You then pay any portion not paid by either Medicare or your Medigap plan.

Your provider may ask you to pay the Part B deductible up front, particularly if they aren’t familiar with Medicare. If you do this, you may wind up being double-billed. There are two ways this may happen.

Common Medicare complaints

The first happens because the provider sent the bill to Medicare AFTER you paid the deductible. Medicare doesn’t know you paid it, so they pay their portion MINUS your deductible and co-insurance amount. The provider then sends you a bill for the deductible amount.

Resolving this is fairly simple, assuming you keep your receipts. You simply phone the provider’s office and remind them that you paid the deductible on the date of service.

The second scenario occurs when you pay your deductible to the provider but then visit a specialist or lab. Often, the second provider bills Medicare first (this is especially true in the event of lab work). Again, Medicare doesn’t know you already paid your deductible. So, when the second provider sends in their bill, Medicare pays their portion minus your Part B deductible. And, of course, that second provider sends you the bill for the remainder.

This second scenario is a bit more difficult to resolve, since it requires getting the first provider to reimburse the deductible.

You avoid this problem entirely by reminding the provider they are to bill Medicare first.

3. Medigap Didn’t Reimburse My Provider for All Services Received

Medicare supplement insurance helps cover a variety of costs. However, it only pays for services that Medicare covers. In other words, you can’t use your Medigap plan to pay for a tummy tuck, dental implants, eyeglasses, or any other service not covered by Medicare.

If you’re sure Medicare covers the service, the issue may be a billing error. Call your provider to make sure the service was billed correctly.

4. My Prescription Co-Pay Is Too High

Your Medicare Part D plan should provide a drug formulary, which is simply a list of covered prescriptions. It likely also uses a tier or step system where drug prices climb along with the tiers.

Part D plans nearly always change their formulary from year to year. That’s why we recommend closely reviewing your plan’s Annual Notice of Change (ANOC). Otherwise, you won’t know if your plan stops covering one of your prescriptions. Until, of course, it’s time to fill it.

Example of a 5-tier drug formulary used by prescription drug plans

If your prescription is more expensive than you expected, start by talking to your drug plan. They can tell you why. It may be that the drug is on a higher tier. It could also be that your pharmacy is not one of their preferred providers. If it’s a tier issue, ask your doctor to submit a request for a tier reduction. Another option is asking whether there’s a similar drug available on one of the lower tiers.

5. My Part B Premium Is Based on My Old Income

Medicare bases your monthly Part B premium on your income tax return from 2 years ago. That means your 2019 premium is based on your 2017 income.

You pay a higher premium in 2019 if your 2017 income was over $85,000 per year (filing individual or married filing separate) or over $170,000 (married filing jointly). This is known as an Income Related Monthly Adjustment Amount (IRMAA) and is added to your monthly premium. The IRMAA varies according to your income level. It changes every year.

Of course, most people experience a change in income once they retire. And few want to wait two years for Medicare to catch up to their new income level. That’s why Medicare and Social Security allow you to appeal the IRMAA if your income changes.

To appeal, contact Social Security at 800-772-1213. You can request an appeal within 60 days of receiving your IRMAA notice.

6. My Out-of-Pocket Costs for My Medicare Advantage Plan Are Too High

One reason we recommend working with a broker (like Medicare Solutions) is to help ensure you truly understand the costs of your Medicare Advantage (MA) plan.

Although all MA plans must cover the same services and benefits as Original Medicare, their out-of-pocket costs are not standardized. And a single visit to your primary care doctor can cost you multiple co-pays if you also need blood drawn, x-rays, or more.

That’s why we advise comparing ALL of the plan’s costs when looking for an MA plan, not just the monthly premium.

The licensed agents at Medicare Solutions can help you find the best Advantage or Medigap plan for you. Just call us toll-free at 855-350-8101. Or, use our online tool to compare plan options in your area.

7. Medicare Won’t Pay for My Durable Medical Equipment

As with medical services, you must use a Medicare-approved provider to receive coverage for durable medical equipment (DME). Make sure you ask the supplier whether they accept assignment before choosing them for your DME.

If you have an MA or Medigap plan, ask your plan’s provider for a list of covered suppliers.

How to File a Complaint with Medicare

If you aren’t happy with the quality of service or care you received from one of your providers, you can file a complaint with Medicare. Also known as a grievance, a complaint is directed specifically against your plan or provider.

Medicare beneficiaries may file a complaint about their doctor, drug plan – basically any entity that you rely on for healthcare services. To file a complaint, talk to your state’s SHIP office.

Appeals are different, reserved for when you disagree with a decision made by Medicare. For more information, please see our article, Understanding the Medicare Appeal Process.

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