Medicare, Medicaid, Life and Health Insurance/Insurance deductable


QUESTION: Hi Tricia. I've been checking my mother's health insurance deductible. I am her caregiver. My mother has blood testing done every other month. The lab charges $65. According to her Medicare records, Medicare only allows $8.50 as a charge, they pay it. I noticed on her insurance deductible, the insurance company is applying the full $65 to her deductible.Even though, she has never had to pay for the testing. Does the insurance count only what is charge for the test and not what is actually paid? Her doctor bills for $54, each visit, but Medicare only allows $47, which my mother pays. The insurance company is applying the full $55 to her deductible. It appears she's getting credit for what she is billed,and not what she has paid out of pocket.

ANSWER: Hey John--

Check the explanation of benefits (EOB) she receives when Medicare pays and there is a section on there that states patient's responsibility.  This is the only amount she will owe.  Medicare allows usually less than 50% of the charged amount and then the patient is responsible for 20% of the "allowed" amount.  

Many offices get confused and do not know how to read the EOB's and start overcharging patients.

I never pay anyone any money until I have my EOB in hand and it states I owe.

Also deductibles are met against the allowed charges not billed charges.

You can always call Medicare to clarify specific invoices.  I can tell you that insurance companies always make mistakes paying so you need to always review.

Good Luck!

---------- FOLLOW-UP ----------

QUESTION: Hi Trica, I did look at the EOB. An example, the blood lab billed Medicare $65. Medicare only paid $8.50. It says "You may be billed 0.00". The insurance EOB, for the same lab shows, a billing of $65. "Copay not covered by deductible...$65". "Amount paid 0.00". She has a high deductible. The insurance doesn't pay the lab. According to the Medicare billing, she doesn't owe anything. According to the insurance EOB, they are crediting her deductible for a $65 payment, she never made. Her doctor bill is no problem, Medicare shows a billing for $47, amount you may be billed, $47. (which she pays). The insurance EOB, shows $47 billed, "Copay not covered by deductible...$47". "Amount paid 0.00". She does pay the $47. The EOB from Medicare and the EOB from her insurance company doesn't match.

ANSWER: Does your mom have a secondary insurance carrier? Not clear who you are speaking of when you say "her insurance company" and not referring to Medicare.

Is Medicare her primary or secondary?  

---------- FOLLOW-UP ----------

QUESTION: She has Medicare supplement F+, along with Medicare. It will pay all cost, after a deductible of $2110.

Medicare allows only a portion and then pays that amount minus copayment.  Copayment is then the responsibility of the secondary carrier however if deductible has not been met then it is the patients portion to pay.  

I would go by what the Medicare EOB says.  

Medicare, Medicaid, Life and Health Insurance

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Has your medical insurance company denied your claim and refuses to pay? Have you received a pre-authorization and still your insurance company refuses to pay? How can you get your insurance company to reverse a denied claim? How do you get a provider to waive your copayment if you are financially unable to pay? Can a provider sue you for a unpaid bill and will they? Can a provider send me to a collection agency for a medical bill? If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay. I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!


In the medical field for over 20 years spending majority of time in the collections aspect.

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