Q & A: September 2021

Why Does My Doctor’s Office Need to Call My Insurer Before Scheduling a CT Scan?

Q: My pulmonologist ordered a CT scan, but the person scheduling appointments said they first had to check my insurance.  Is this correct?  I’m covered by Medicare and a Medicare Advantage plan.  I thought I would be covered for any medically necessary CT scan.

A: Computed tomography or CT scans are diagnostic tests that are covered by Medicare when medically necessary and ordered by your healthcare provider.  Medicare most typically covers the tests under Part B when you are an outpatient, or the tests would be covered by Part A if you receive the CT scan as an inpatient during a hospital stay.           

Medicare Advantage plans combine both parts of Medicare, and the health plans are required to cover everything that is covered under original Medicare.  However, your provider may be reporting your doctor’s orders to your Medicare Advantage plan in order to get prior authorization for your CT scan.  Most Medicare Advantage plans routinely require prior authorization to manage your care and to prevent excess use of care that has not been documented as medically necessary.  This practice protects you from surprise bills, and confirms that the provider is authorized to bill your Medicare Advantage plans for your care.

The amount you pay for your CT scan will vary by your Medicare Advantage plan and whether you get your CT scan from a preferred provider.  You will need to call your plan to learn the out-of-pocket cost details, and to make sure the facility, doctors, and medical technicians performing the CT scan are preferred providers with your Medicare Advantage plan.  You could pay considerably more if you use providers who are not under contract with your Medicare Advantage plan.  Call the customer service number on the back of your health plan’s card, have your questions written down and be ready to take notes.

And, in case you had any doubts about why you need that Medicare Advantage plan in the first place, here are the general types of costs if you have Medicare Advantage plan coverage compared with having traditional Medicare with a Medigap supplement.

  • Deductibles:  This is the amount you pay out – of – pocket before your insurance coverage kicks in.  Most people get CT scans as outpatients under Medicare Part B, which has a deductible of $203 in 2021, meaning you might be responsible for that amount.  If your scan is part of a hospital stay as an inpatient, it would bill under Part A which has a deductible of $1,484.  Because you are enrolled in a Medicare Advantage plan, your deductible amounts can vary from the standard Medicare amount.  It’s a good idea to call your health plan before getting any services, to get an idea about the cost.  For people covered by a Medigap supplement, it will cover the Part A deductibles but, as of January 2020, insurers are no longer allowed to sell plans that cover the Part B deductible, Plans C and Plan F to new enrollees.
  • Co-pays and coinsurance:  This refers to the portion of the cost of services that you pay out-of-pocket.  Co-pays are a fixed amount that you will pay for each service.  For example, in a Medicare Advantage plan, you may be billed a co-pay of $25 to see a primary care physician and $50 to see a specialist.  On the other hand, coinsurance is a variable amount.  It is a percentage of the cost of the service.  Theoretically if the total cost of the service is $2,000 and you pay 20% coinsurance, your cost could be about $400.  Under Medicare Advantage your health plan negotiates the cost of service, thus you would want to call your plan to get an idea what your total out-of-pocket costs would be, and whether your provider is a preferred provider.  Under most Medigap policies, the Part B co-insurance cost is covered in large part, but there still could be some “excess charges” that you pay out of pocket.