How MS plans pay claims

Medicare Supplement: How does a Medical Claim under a Medicare Supplement policy work?

Let’s say you start MediGap plan G and your first claim under the plan is a visit to an orthopedic surgeon’s office where you have the office visit, an x-ray and a cortisone shot.

You’ve given the provider your Medicare card and your MediGap plan card. They electronically submit a claim to Medicare. If you have registered your account at Medicare.gov you can electronically review Medicare’s Explanation of Benefits (EOB), which is the document that outlines how Medicare adjusted (or processed)  the provider’s claim.

The EOB will show a few things.

• What services were provided by whom on what date
• “Total Amount Charged” – How much the provider charged for the services provided
• “Medicare Approved” – How much Medicare allowed the provider to charge for those services
• “Total Amount You May Be Billed” – The amount left over after Medicare pays their share (which is generally 80% AFTER you’ve met the Part B deductible)

Once this is sent back to the provider, they will then bill the Medigap plan who will, adjust the claim, and generate THEIR EOB, which is available online if you register with the company there. As before, their EOB will show the total amount charged, the company-approved amount, and the total amount you may be billed.

If you have Medigap plan G, you are responsible for the Part B deductible only. Medicare pays 80% after the deductible and the Medigap plan pays the other 20%.  But with that deductible to satisfy, your first claim or two each year will get adjusted and ultimately be billed to you.