The Medicare Whisperer: Don’t Assume Your Referral Is Covered
After a recent morning shower, Bob, who’d recently retired, noticed a dark spot on his shoulder. His wife suggested he see his primary care doctor (PCP) and get it checked out.
Bob did, and after inspecting the spot, his PCP referred him to a dermatologist specialist. During that appointment, the dermatologist examined then removed the spot. “Nothing to worry about.” Bob drove home relieved.
Soon after, he received an Explanation of Benefits (EOB) from his insurance company. This detailed all of Bob’s medical visits in the past month, noting what was covered, and what costs, if any, were Bob’s responsibility.
Bob was surprised to see that his recent visit to the dermatologist was not covered. The EOB said the dermatologist was out of network according to his Medicare plan.
Like many would do, Bob assumed his PCP’s referral to the specialist would be covered, aside from any of his plan-specified copayments.
Unfortunately, that’s not always the case
Like Bob, many on Medicare think: “My doctor is referring me to a specific specialist, so they must be in network.”
While many PCPs make every effort to refer patients to providers in network, the reality is networks can change throughout the year, and not every office has access to a patient’s plan’s current network information.
Specialists’ offices often verify coverage before an appointment, and many will contact the patient if they discover they are out of network. However, mistakes happen, and patients think everything is fine. . . until they later learn the truth from their EOB.
The Good news: This is preventable — here’s how:
Before scheduling an appointment with a specialist, imaging center, or lab, call your Medicare plan.
Ask whether the provider, imaging center, or lab is currently in network with your plan. Even if your PCP’s office tells you the specific entity is in network, always confirm directly with your insurance, and document the date, time, and name of representative who advised you.
“What happened to Bob happened to me. What can I do now?”
If you discover that a claim was denied because the provider was out of network, you have options:
Contact your Medicare plan immediately to determine why the claim was denied and to ask whether an appeal or other review is available. Depending on the circumstances, the representative may request additional information, or they will explain the next steps.
If an appeal is suggested, write a letter to your insurance company. This is your opportunity to explain that your PCP’s office referred you to an out-of-network provider or lab unbeknownst to you. Also note that the out-of-network provider or lab never advised you of their status before your appointment. State that If you’d had this information beforehand, you would never have gone to the appointment in the first place.
Keep in mind that even after an appeal, you may still be responsible for the bill if the denial is upheld.
The best strategy: Avoid this surprise altogether!
One quick call to your insurance company before your appointment will help you confirm your coverage, avoid unexpected expenses, and give you peace of mind. When it comes to your Medicare plan, verifying that a provider is in network is one of the simplest and smartest steps you can take to protect both your health and your wallet.
Julie Van Dyke
50plus Magazine
Julie VanDyke is a freelance writer committed to simplifying Medicare for all.