What is one to do when a patient wants a claim to be resubmitted after her deductible is met when the claim was originally submitted prior to the deductible being met?
The 2023 Medicare deductible is 226.00 What that means is that the first 226.00 of covered services that are provided by physicians and by other qualified health care providers to a Medicare recipient that would be reimbursed at 80% of the covered Medicare allowable amount would automatically be applied to the patient’s deductible until the 226.00 is met. Some patients have a super, great supplemental insurance that not only covers the 20% that Medicare does not cover, but also covers the 226.00 Medicare deductible. Most patients do not have this secondary coverage and are therefore responsible for the 226.00.
What do the providers do? Well, most providers submit the claim for the services provided to the Medicare Administrative Carrier and when the EOM states how much of the reimbursement went to the patient’s deductible, the patient is sent a statement for the amount that went to the deductible. Other providers will “sit on the claim,” so to speak. What this means is that they do not submit the claim in the hope that the other providers that the patient sees in the same time frame will use up the patient’s deductible and the initial provider will be paid by the Medicare Administrative Carrier.
With respect to the patient asking for the claim to be resubmitted since her deductible is now met, I am sorry. This is a “one bite of the apple” scenario. When the claim for services rendered was originally submitted to the Medicare Administrative Carrier the amount for covered services provided went directly to the patient’s deductible. It is inappropriate to resubmit “now that the deductible has been met.” The patient certainly has the option of contacting the Medicare Administrative Carrier and hashing it out with them.
This is my opinion.
Michael G. Warshaw
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