Social Security & Medicare Questions: Medicare Network Providers

Social Security & Medicare Questions: Medicare Network Providers

Q: Recently my husband became seriously ill and required surgery. Afterward we received several unexpectedly high bills. We learned that one of the surgeons, and the anesthesiologist, were not in our plan network. Can you tell me what doctors are allowed to bill people enrolled in a Medicare Advantage plan?

A: What you pay out-of-pocket depends on a number of factors that include the following:

• The type of Medicare Advantage Plan your husband is enrolled in. In most Health Maintenance Organizations (HMOs), for example, you can only use doctors and other healthcare providers in your plan's network, except in an emergency. You may also need to get a referral from your primary care doctor. If your plan is a Preferred Provider Organization (PPO), you pay less if you use doctors and healthcare providers that belong to the plan's network and more if you use doctors and providers outside of the network. Under Private Fee-For-Service (PFFS) Plans, you can generally go to any doctor or healthcare provider, as long as they agree to accept your coverage. The plan determines how it will pay doctors and other providers.

• Use of network providers. If your doctor or other healthcare provider doesn't belong to the plan, the services provided may not be covered, or your costs could be higher. In most cases this applies to Medicare HMOs and PPOs.

• Deductibles and cost sharing. If your plan has a yearly deductible or any additional deductibles for the services your husband received, that may be a factor in the unexpectedly high cost. The deductible is the amount you must pay out-of-pocket before your plan covers the claim.

• Plan fee structure. If you are enrolled in a PPO, it may cover some portion of your husband's care from providers outside your plan's provider network. Some plans use Medicare's fee for a specific medical procedure as a base, and then multiply it by a certain percentage to develop the maximum amount that they will pay for that procedure. For example, your insurer may agree to pay 130% of the rate Medicare normally would pay for the visit. But even if your plan’s out-of-network rate is higher than Medicare's fee schedule, it could still be less than what you are charged. This is particularly true for specialties like surgery and anesthesiology, as well as outpatient services like radiology and lab visits.

Example: If Medicare would normally pay $1,000 for the procedure and your insurer pays up to $1,300, you pay any uncovered balance. If your provider charged $2,000, and your plan paid $1,300 that leaves you to pay $700. But if you had a $1,000 deductible, you would be responsible for $1,700.

If you are still unsatisfied, get free counseling to help unravel your bills from your State Health Insurance Assistance Program (SHIP). To get the contact number of a SHIP counselor in your area, check online for the contact information at or call 1-800-MEDICARE (1-800-633-4227).