What if your doctor recommended some expensive blood tests that Medicare would not cover? . That’s what happened recently to Kim Hanks. Unfortunately, she didn’t find out until after her blood tests were complete that Medicare would not pay for them.
This Medicare beneficiary says she’s left with a $732 blood test bill, and she hopes Consumer Rescue can help.
Hank’s experience serves as a cautionary warning for all Medicare beneficiaries.
Just because a doctor or other provider suggests a test or procedure doesn’t mean Medicare will pay for it. Ask your doctor some questions. Primarily, you need to know if Medicare will consider them “medically necessary.” If not, you, like Hanks, could be on the hook for an unexpected bill.
Doctor-recommended blood tests
During a medical visit, Hanks’ doctor suggested some blood tests which could be done at a lab conveniently located nearby. The lab drew the blood, did the tests, and submitted the bills to Medicare.
While Medicare Part B and her Medicare supplement plan covered the doctor’s visit and many of the blood tests along with the 20 percent copay, it denied coverage for six of the tests the doctor ordered. That left her with that $732 bill.
I signed an Advanced Beneficiary Notice (ABN) when I visited (the medical practice). (They) miscoded lab tests done by (the lab) and so my insurance, Medicare and Anthem Blue Cross, denied the claims. The doctor’s office claims it doesn’t have to correct the coding because of the ABN and the lab claims it can charge “anything it wants” because of the ABN. Is this correct? I feel I’m being lied to and taken advantage of. $732 is at stake.
Hanks was angry, as most of us probably would be if we were hit with a large unexpected bill. However, Medicare rules are complicated. Procedures that you think will be covered often aren’t. That’s the case here. Let’s start by looking at the notice she was asked to sign.
What is an Advanced Beneficiary Notice (ABN)?
If you have Original (fee-for-service) Medicare, a doctor or other provider will ask you to sign an ABN if they know or think that some of the services they’ll provide won’t be covered. You have three options if you are asked to sign one:
- Get the services and ask that the charges be submitted to Medicare while agreeing to assume financial responsibility if Medicare does not approve the charges. If Medicare denies coverage, you will have the right to appeal.
- Agree to pay the charges without them being submitted to Medicare.
- Decline the services in question.
You can find a more detailed explanation of the ABN and your rights on the Medicare website.
Many medical practices will ask a patient to sign one as a routine matter, especially if the patient is new or is having some kind of outpatient surgical procedure.
Did the doctor make a coding mistake?
We don’t know whether Hanks’ doctor thought a specific blood test might not be covered. I’ve found that doctors often don’t have a good understanding of Medicare rules. If you are asked to sign an ABN by your doctor or other provider, it’s OK to ask what particular services may not be covered.
Did Hank’s doctor miscode the lab tests, as she claims? I would be surprised if that were the case. The doctor wrote the lab order for specific tests and the lab did the requested work. The lab can indeed charge whatever it wants for blood tests. However, since the lab agreed to bill Medicare, it has to accept Medicare’s contract rate as total compensation for covered services. But the lab can charge patients its going rates for services that insurance does not cover.
Hanks’ doctor declined to change the coding on the lab order. The real issue is not whether the codes were correct, but rather whether the doctor could honestly show that the tests in question were medically necessary.
Warning: Medicare doesn’t always cover blood tests
Sometimes, Medicare will cover blood panels and specific tests under certain conditions while it denies coverage for those same tests under other circumstances. There are several factors that come into play, but the key factor is medical necessity. For many of them, the doctor has to make a case that the test in question is medically necessary to confirm a diagnosis or to manage a specific condition for that particular patient.
Let’s look at one of the tests Hanks’ doctor ordered – one that checks vitamin D3 level. That test might be covered if the doctor needed to confirm a diagnosis of a D3 deficiency, which she does not have, or to treat specific conditions (listed on the Center for Medicare and Medicaid Services [CMS] website) which she also does not have.
All of the other denied tests, except one, had similar conditions attached. The exception was a test that Medicare does not cover at all and for which the ABN is required.
Doctors don’t know everything (and I mean no disrespect)
I once had a specialist suggest a blood panel that included a D3 screen. When I asked if he thought I might have a D3 deficiency, he said no but that it would be worth just checking. I asked him to not include that in the lab order and explained why.
In my role as a registered Medicare counselor, I met with a woman who wanted to appeal a Medicare denial of a certain blood test. When I read her the CMS requirement that the test has to be related to a specific condition, she understood right away because she was a retired nurse and was knowledgeable about that condition.
If a doctor suggests a blood test and uses terms like “routine” or “just to see,” ask why they think it’s medically necessary. Remember, that’s what Medicare will consider in deciding whether it pays — or you pay.
Read your Medicare Summary Notice
After a doctor or other provider submits a bill to Medicare for services for you, Medicare will notify you via a Medicare Summary Notice (MSN). It will summarize all of the services billed to Medicare by your doctors and other providers. It will show the provider, the amount billed, whether Medicare approved the charge, the amount Medicare actually paid, and the maximum amount you might owe. If you are in a Medicare Advantage (Part C) plan, the notice you get is called an Explanation of Benefits.
You can view the MSN in your Medicare.gov account or have it sent to you by U.S. Mail.
It’s important that you read it. Hanks apparently did not read hers. If she had, she would have seen that Medicare did not approve coverage for certain tests and each denied charge would show a code and notes explaining why.
Remember, if Medicare does not approve a charge, your Medicare supplement plan will not pay either.
I’ve written about other Consumer Rescue readers who got hit with surprise bills for services that Medicare did not cover in this article, and where I also explained how to read and understand the MSN.
I told Hanks that she had the right to appeal the Medicare denial. She said she had already done so and is awaiting the response. Unfortunately, I had to tell her that, in my opinion, her appeal would unlikely be successful.
Avoiding problems
It’s important that you understand the specific tests your doctor thinks you should have. If it’s not urgent that you get to the lab the same day, take some time to do your research. The official Medicare website has a search function to see if a procedure is covered. You can also do an online search of “Does Medicare cover the _________ test?” The results will often include links to the CMS pages that detail requirements for payment.
Medicare coverage rules can be confusing.
A great source of free, unbiased and knowledgeable Medicare information is the State Health Insurance Assistance Program (SHIP). It’s federally funded and available in every state.
Of course, you can also submit your Medicare questions to me here at Consumer Rescue.
Watch Out for this “Not Junk” mail
In the next few weeks, all Medicare beneficiaries will be getting an important piece of mail that may look like junk mail but that you must read.
It’s the Annual Notice of Change that all Medicare Advantage and Medicare prescription drug plans are required by law to send in advance of Medicare’s Annual Enrollment Period (Oct. 15 – Dec. 7).
Watch for my upcoming article on why it’s especially important this year to pay attention to that notice. (Abe Wischnia, Special features columnist, Consumer Rescue)
My mother in law is of an older generation that simply doesn’t push back on what doctors tell them. She’s had some dubious tests and checks that she would never question. I wonder how many medical practices prescribe things to “make up” for lower Medicare reimbursements?
Worked for 20+ years in Rehab and Post Acute Care as a consultant for SNFs. Am a retired RN.
The intent of the use of ABNs was to notify beneficiaries of non-coverage/payment because Medicare criteria was not met prior to service being provided. Such as rehab goals met and family still wanted Physical Therapist to walk beneficiary everyday. MD would write order-so it needed to be done as ordered. It did not meet Medicare criteria so ABN issued. Form needs to show: Cost of each treatment, reason for non-coverage (such as beneficiary met all physical therapy goals at time of discharge), date, and name of beneficiary on letter. Then it was signed and dated by beneficiary or their appropriate rep.
What I have encountered post retirement has been interesting.
#1. Given a blank ABN letter by one of office staff to sign. Reason for blanks on ABN: it will be completed after procedure or exam for what it will cost. Reason for letter, “just in case Medicare does not pay for the visit today”
Have asked for copy of the blank letter to use in appeal process Business Office Manager called in by Medical Assistant, Business Office explained “situation” to MD in who said forget it and did exam.
#2. Latest, was when I had a colonoscopy by board certified gastroenteritis as part of Medicare every 10 year screening. Upon check in had to sign the ABN form to have the procedure done! Husband had same procedure at another site same gastroenterologist uses and no ABN form needed.
ABN must be issued and signed prior to exam, treatment, or service deemed by provider as non-covered.
Office staff requesting signature on ABN ften have been clueless why it was needed other than they were told to do so. Do not be afraid to request clarification from provider and/or knowledgeable staff. If payment denied, complete an appeal to contracted insurance company.
No time for beneficiary to check reference materials in CMS manual? Obtain a copy of the form. If areas left blank identify blank areas with initials and date and time prior to receiving a copy of form Use references from online CMS Manual as Abe identified to write appeal, if needed.
Often Business Office bonuses may include calculations based on Medicare charges denied due to non covered services provided.
Had to speak my peace. Thank you for listening.
Thank you for posting this. Your example in #1 is very important. Just as you should never sign a blank contract, you should never sign a blank ABN. Presenting a patient with a blank ABN is a violation of CMS rules. For the ABN to be valid, it must show, among other things, the services the provider thinks may not be covered along with a good faith estimate of how much they would cost. And you must be given a copy of the filled-in and signed document. If there are any blanks, note them with your initials and date.
I got my ANOC on 9/27/24. My premium is going from $3.70/month to $38.70/month, so yeah, everybody better read the letter. Mine is about 15 or so pages. It’s a booklet. Once we get to Oct 15th I will be reviewing the plans that are out there.
You have probably written about another topic in previous columns, but I would like to point out the IRMAA letter. What caught me by surprise last year is the definition of adjust gross income. I was not any sort of cpa or business person in my career (computers were my thing), but I did do my own taxes every year. I sold my house in the fall of 2022. And during 2023 I was watching YT videos about SSA, Medicare, etc. And when they spoke about IRMAA they all said AGI. And my brain went to well, yeah, after my deductions adjust my income, I won’t have that kind of income, so I won’t get an IRMAA letter.
Oops. The long and short of it as you know is that number that gets compared is the income right before you deduct your deductions (standard or itemized). It was line 11 in the 2022 1040 form. That is what I wished the YT hosts had stressed. Then I would have known it and could have do a little better planning and budgeting for this year.
So for anyone reading this comment all the way to the end, check your AGI not the after-the-deduction number. And since my income was capital gains, my appeal was denied. At least going forward I won’t have any IRMAA hit, since I had no income in 2023 and don’t expect to have the kind of numbers that generate the adjustment.
IRMAA (Income Related Monthly Adjustment Amount) is based on Modified Adjusted Gross Income (MAGI), which is the sum of:
It’s based on the most recent tax return that the IRS is able to provide to Social Security. If you want a deeper explanation of how the IRMAA amounts are calculated and the rationale, you can find it here in the Program Operations Manual System of the Social Security website:
https://secure.ssa.gov/poms.nsf/lnx/0601101031
There are opportunities to appeal an IRMAA assessment. But generally speaking, a one-time capital gain from the sale of an asset can kick you into the IRMAA tables.