Hospital outpatient services should be billed the same as doctor services. That is, Medicare should evaluate the total charge, and provide an approved amount. There should not be discrimination between the doctors’ claims and those of the hospital. I rely on the Medicare approved charge schedule for a fair and equitable evaluation of (the rate I should pay for) the Medical services I receive from the doctors and hospitals. -- A.F.C.

From the editor: Medicare recipients should not have to pay a higher coinsurance or co-payment amount for hospital outpatient services, than they do for similar doctor services. Despite recent legislative changes, this continues to be the case. Under most Medicare Part B fee-for-service claims, after you pay your deductible ($100 in 2001), Medicare pays 80% of the Medicare-approved charge and you pay 20% coinsurance. Hospital outpatient services are different.

Until recently, Medicare paid 80% of the Medicare approved charge and you paid 20% of the hospital charge, which in many cases was higher than the Medicare-approved charge. In the past beneficiary coinsurance accounted for about 50% of the total payments to hospitals.

Under the new system you are responsible for the yearly $100 Medicare Part B deductible, and depending on the service you receive, 20% coinsurance OR a fixed co-payment amount for each service you get in an outpatient visit. The co-payment amount cannot be more than the Medicare Part A inpatient hospital deductible which is $792 in 2001.

Because the new rules will not be fully phased in until 2004, the 20% coinsurance might continue to be 20% of the hospital charge instead of 20% of the Medicare approved charge (again depending upon the service you receive). The major difference being the limitation of $792 per service.

Once your bill is processed you will get a Medicare Summary Notice or Explanation of Medicare Benefits. This notice will have a section showing the total deductible and coinsurance amount you are billed for the services you received. If you have other supplemental insurance it may pay for some of these costs.

One factor that led to higher hospital outpatient charges in the past appears to have been inflated drug prices used in some outpatient drug therapies. The maker of a top-selling prostrate cancer drug, Lupron, is expected to pay a record fine of more than $840 million to settle allegations that it inflated prices and bribed doctors to prescribe it.

In addition to the federal case, patients who took Lupron have filed a class action lawsuit asserting they were overcharged by millions of dollars as well. Lupron patients on Medicare often paid more than $1,000 a year for the drug. New billing rules for outpatient drug therapies became effective January 1, 2001. Now the doctor, or hospital cannot charge patients more than Medicare allows.

For more information visit (http://www.medicare.gov/publications/pubs/pdf/opps.pdf). or call 1-800-MEDICARE (1-800-633-4227).

To read more about Medicare, click here: http://www.tscl.org/medicare.asp.

August 2001