The Medicare website gives direction regarding the amount that a patient should expect to pay for medical services under Medicare provisions. This information is helpful to ensure you aren’t overcharged for medical procedures and prescriptions.

What To Do When You Are Overcharged

The first step is to call the customer service department of your insurance carrier. There are several Medicare options in which you can be enrolled, so the coverages can be confusing. Medicare Advantage, Medicare Supplement and Original Medicare have different rules and limits on what they will pay, so speaking with a customer care person may help clear up some of the discrepancies.

If you and your customer service professional verify that there is an error, they should be able to correct the situation in most cases. Incorrect coding is an easy error to fix. Fraud and abuse, however, are much more serious and more difficult to remedy. Examples of dishonest billing include:

  • Billing for services or medical supplies that were never prescribed and provided
  • Billing for more complex conditions than were present, sometimes called “upcoding”
  • Charging for appointments the patient wasn’t able to keep

How Medicare Charges Are Monitored

As a way of correcting coding errors, a statistical system was developed to classify inpatient stays into groupings. This system, called Diagnosis-Related Group, allows for over 20 major categories, which are each divided into several groups. With so many groupings, however, it isn’t always easy to assign the proper code to the procedure. DRG auditors to review a sampling of patients to see how they were diagnosed and treated. The auditor then checks how the claim was coded to either validate or invalidate the coding. If an improper code is found, it is corrected by the auditor and the payment is recalculated.
Patients and health care providers can have the peace of mind knowing that the proper codes have been applied when DRG audits are performed.