Medicare has two billing parts. Medicare Part A (hospital insurance) helps to pay for inpatient hospital services. Medicare Part B (medical insurance) helps to pay for clinic services, doctor fees and outpatient hospital services.
Your out-of-pocket expenses depend on whether your doctor or supplier of health care equipment and supplies agrees to "accept assignment" (the Medicare approved payment amount). To obtain the most current information, visit Medicare's website or call 800-MEDICARE (800-633-4227) (toll-free).
Basics of original Medicare
Although Mayo Clinic provides medical services to Medicare patients, Mayo Clinic doesn't accept assignment from Medicare for professional and physician services. In other words, Mayo Clinic doesn't accept the Medicare-approved payment amount as full payment. Mayo Clinic follows an established fee schedule based on the federal guidelines for Medicare patients, which allows health care organizations to charge up to 15 percent above the Medicare allowable fee. You're financially responsible for the portion above the Medicare allowable amount.
This example shows how Medicare calculates your benefit:
|Example of Medicare benefits at Mayo
|Mayo Clinic charge
|Medicare approved amount
|Medicare pays 80% of approved amount
|Secondary insurance pays 20% of approved amount *
|Total paid by Medicare and secondary insurance
* The secondary insurance reimbursement may vary depending on your Medigap policy. Some policies may cover additional charges than in the example. For more information, please visit the Medicare website.
Mayo Clinic — Physician services
Are there services for which Mayo Clinic must accept assignment from Medicare?
Yes, services include:
- Laboratory tests covered by Medicare
- Physician assistant services
- Nurse anesthetist services
- Ambulatory surgery center charges
How can I tell if Medicare assignment was accepted for a particular claim?
Each of your Medicare Summary Notices (MSN) will indicate whether Medicare paid your provider — Mayo Clinic — or you.
Is there a difference in the way Medicare processes assigned and unassigned claims?
Yes. Some of the differences are:
- Medicare pays Mayo Clinic directly for assigned claims, but pays you directly for unassigned claims.
- Medicare sends a copy of the Medicare Summary Notice to Mayo Clinic for assigned claims, but sends you a copy of the MSN for unassigned claims.
- You're responsible for forwarding any Medicare and insurance company payments to Mayo Clinic.
Mayo Clinic — Hospital outpatient services
Are hospital outpatient services paid by Medicare?
Yes, Medicare Part B pays for many of the outpatient services you receive in a hospital under the outpatient prospective payment system (OPPS). Hospitals are paid on a separate fee schedule for providing certain outpatient services to people with Medicare. You will be responsible for a copayment amount for each service.
What is a copayment?
A copayment is defined as an amount you may be required to pay as your share of the cost for a medical service or supply. A copayment is usually a set amount, rather than a percentage.
What services are paid for under OPPS?
Part B services paid for under OPPS include but are not limited to radiology, emergency department visit, outpatient surgery, and observation to decide if you need inpatient care for an illness or injury.
What is my responsibility (out-of-pocket expense) in a hospital outpatient setting?
The hospital will bill separately from the physician bill and you will be responsible for a copayment amount for each service provided. Other than your annual deductible and the copayments, Medicare's payment will pay the balance of the covered services provided by the hospital.
Are there services Medicare doesn't cover?
Medicare pays for much, but not all, of your health care. Your out-of-pocket expenses depend on several factors, such as the type of service, diagnosis, frequency of service, and so on. Medicare doesn't pay for certain services such as regular dental care and regular eye exams. Medicare may or may not pay for services or procedures that it considers routine or preventive. An example of a noncovered service is the routine or preventive component of your annual checkup. An itemized statement of charges showing two charges for one office visit may raise questions. This can happen because Mayo Clinic must bill the routine and preventive portion of your visit separately. Please refer to the federal government's Medicare website for more information.
There are other specific instances in which Medicare may deny payment. In such cases, you may receive an advance beneficiary notice (ABN) from your doctor, other providers or suppliers to let you know in advance that Medicare may not cover the service. The ABN will tell you:
- That Medicare will probably deny payment for that service or item
- The reason your doctor, provider or supplier expects Medicare to deny payment
- That you'll be personally responsible for the full payment of the bill if Medicare denies payment
- That you can refuse to receive the service or item
What to expect from Mayo Clinic billing
- Mayo Clinic automatically bills Medicare for services you receive.
- Medicare sends you the payment and Medicare Summary Notice (MSN) for Mayo Clinic unassigned services.
- If Medicare and your secondary insurance company have agreed to accept crossovers, Medicare automatically forwards the MSN to your secondary insurance company. The "Notes Section" of your MSN will read, "This information is being sent to your private insurer(s)."
- Mayo Clinic sends you an itemized statement of charges after each visit. The charges are listed on the statement only once. The monthly statement of account that follows will reflect a balance forward and subsequent activity.
- Mayo Clinic sends you a monthly statement of account and expects payment of the current amount due from you when you receive the statement.
- When you receive Medicare and secondary insurance company checks, Mayo Clinic recommends that you deposit those checks into your bank account and issue a payment to Mayo Clinic. Include the lower portion of the first page of your billing statement with this payment.
- You'll receive a monthly statement of account in every month that you have a balance.
Medicare reimbursement denials and disagreements
- If Medicare denies a charge and your Medicare Summary Notice states that you're not responsible for the charge, please call Mayo Clinic at 480-301-7033 for adjustment or resubmission of the claim. Please call 800-603-0558 (toll-free) if you're calling outside the Phoenix metropolitan area.
To appeal a denied charge when Medicare states you're responsible for the charge, follow the instructions under "Appeals Information" on the last page of your Medicare Summary Notice. The Medicare website provides information about appealing Medicare decisions. You also may call Medicare at 800-633-4227 (toll-free).
You must file an appeal within six months of the date of the notice. As a nonparticipating provider with Medicare, Mayo Clinic isn't permitted to initiate appeals on your behalf in most instances. However, we will assist by providing Medicare or other insurers with any information requested to review your case.
- When Medicare states that you're responsible for the denied charge, please be aware that Mayo Clinic expects payment from you and will continue to send you a monthly statement until your account is paid in full.
The laboratory that performs your tests automatically bills Medicare.
Many laboratory tests can be performed on a single blood draw or sample collection. Most laboratory testing on samples drawn at Mayo Clinic is performed on site. If you have a specialized test ordered by your doctor, your sample may be sent to a reference laboratory that is outside of Arizona. If you have a specialized laboratory test performed outside of Arizona, you may receive more than one Medicare Summary Notice and more than one itemized statement of charges. Mayo Medical Laboratories in Rochester, Minnesota, is a specialized laboratory commonly used by all Mayo Clinic locations.
For questions about charges billed under Mayo Medical Laboratories, please call 800-447-6424 (toll-free). You may also send correspondence to:
Medicare Advantage Plans (MAPs)
Medicare Advantage Plans are plans offered by private companies that contract with Medicare to provide all of your Medicare Part A and Part B benefits. In most cases, Medicare Advantage Plans also offer Medicare prescription drug coverage. There are various types of Medicare Advantage Plans, including HMO, PPO, cost based, HCPP, Medicare Medical Savings Account and private fee-for-service plans.
Mayo Clinic's campus in Arizona sees only people who have Medicare Advantage Plans that are contracted with Mayo Clinic's campus in Arizona. Mayo Clinic doesn't agree to the terms and conditions of noncontracted Medicare Advantage Plans due to administrative and financial challenges. Your Medicare Advantage Plan can give you a list of in-network providers.
Additional Medicare information
More information about Medicare is available at the Medicare website.
For questions regarding your Medicare Part B claims for services that you incurred in the state of Arizona, call Medicare at 800-633-4227 (toll-free).