Marci's Mailbox: How Do I Find Out If I'm Liable for A Service Medicare Did Not Cover?

The following appeared in the March 10, 2003, issue of Dear Marci, a FREE online newsletter from the Medicare Rights Center.

Q: I was recently billed for a service, but I did not know that Medicare would not cover this service.  My friend told me that I might not be liable for this charge.  How do I find out?  Do I need to appeal? — Alicia (Cheyenne, WY)

A: Medicare will only cover services or items that are deemed medically necessary.  However, you will not be responsible for the cost of a service if:

• Medicare covers the service when medically necessary and
  
  
• You neither knew, nor could reasonably have been expected to know, that the service was excluded from coverage.

When you knew or should have known that Medicare would not pay for the service on the grounds that it was not medically necessary, you are responsible for the cost of the service.  Medicare decides whether you should have known it would not pay.  The decision is based on whether you were previously notified that Medicare would not cover the service or whether the doctor notified you in writing that Medicare would not pay for the service but, after being so advised, you agreed to get it.  This notification, called an Advanced Beneficiary Notice (ABN) or a Waiver of Liability, is a notice that doctors are required to issue when they provide services they know or have reason to believe Medicare will determine to be medically unnecessary and therefore will not pay for. 

In your case, if you did not sign an ABN, and Medicare covers the service when medically necessary, you should appeal the bill on the ground that you neither knew nor were informed by Medicare or your doctor that Medicare would not cover the service.  To appeal, write "Please Review" on your Medicare Summary Notice (MSN), sign it and send it to the address on the MSN.  Include a letter explaining why you should not be liable for these charges.  Don't forget to make copies of all correspondence and to send your letter by certified mail. — Marci
 
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The Medicare Rights Center (MRC) is a national, not-for-profit consumer service organization working to ensure that older adults and people with disabilities receive high-quality, affordable health care.  For more information about MRC visit the web site: http://www.medicarerights.org or write to: The Medicare Rights Center, 1460 Broadway, 11th Floor, New York, NY 10036.

July 2003

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