7 Questions to Ask Before Your Next Medical Appointment When You Have Medicare

A few questions before you receive care could help prevent an unexpected bill later.

One of the things I tell my clients is that having good Medicare coverage and knowing how to use that coverage are two different things.

You can do everything right when choosing your Medicare coverage and still run into an unexpected bill because of how a service was provided, where you received it, or how it was billed.

That’s why Medicare education shouldn’t stop after you enroll.

Here’s something many people on Medicare aren’t told: There are questions you can ask before receiving care that may help you avoid problems afterward.

Here are seven I think every Medicare beneficiary — and their family members — should know.

1. Don’t Just Ask, “Do You Take Medicare?”

If you have Original Medicare, there’s a better question:

“Do you accept Medicare assignment?”

A provider who accepts assignment agrees to accept the Medicare-approved amount as payment in full for covered services. You may still be responsible for your deductible and coinsurance, but the provider agrees to Medicare’s payment rules.

Most providers accept assignment, but Medicare recommends checking.

You can learn more about Medicare assignment and what it means when a provider accepts Medicare directly from Medicare.gov.

If you have Medicare Advantage, you’ll want to ask a different question:

“Are you currently in-network with my specific Medicare Advantage plan?”

Don’t assume that because a doctor’s office “takes Medicare,” it accepts your particular Medicare Advantage plan.

What you can do: Verify this before seeing a new doctor, specialist or other provider.

2. Ask Whether the Office Is Hospital-Owned

Your doctor’s office may look like any other medical office but be owned by or affiliated with a hospital or health system.

That distinction can matter.

Depending on the facility and how the services are billed, receiving care in a hospital-based setting can affect what you pay.

Before a visit or procedure, ask:

“Is this considered a hospital-based facility, and should I expect a separate facility charge?”

This is especially worth asking when you’re being sent somewhere new for testing, imaging, a procedure or specialist care.

What you can do: Ask about both the professional charge and any facility charge before receiving non-emergency care.

3. Know What Your Medicare Wellness Visit Actually Covers

Here’s one that surprises a lot of people:

Medicare’s Annual Wellness Visit is not the same thing as a traditional annual physical.

The Medicare Wellness Visit focuses largely on prevention and creating or updating a personalized prevention plan.

Medicare says you generally pay nothing for the covered Wellness Visit if your provider accepts assignment.

However, if your provider performs additional tests or services during that same appointment that aren’t covered under the preventive benefit, you may have coinsurance or a deductible — or, for a non-covered service such as a routine physical, potentially be responsible for the full cost.

So if you go in for your Wellness Visit and also need another medical issue evaluated, don’t assume everything discussed that day will automatically fall under the no-cost preventive benefit.

Medicare explains what’s included in the Yearly Wellness Visit and what you may have to pay.

What you can do: Before the visit, ask what is included in your Medicare Wellness Visit and whether addressing additional concerns could result in another charge.

4. Before a Test or Procedure, Verify the Coverage Requirements

Your doctor recommending a service doesn’t necessarily answer every insurance question about that service.

This is particularly important if you’re enrolled in Medicare Advantage because plans may have network requirements, prior authorization requirements or other coverage rules.

Before a scheduled MRI, procedure, surgery, therapy program or other expensive service, ask:

“Has my Medicare coverage been verified, and are there any authorization or network requirements I need to meet?”

Then verify with your Medicare Advantage plan when appropriate.

What you can do: Don’t wait until the day of an expensive procedure to find out whether all of the coverage requirements were met.

5. If You’re Asked to Sign an ABN, Read It

If you have Original Medicare, you may occasionally receive something called an Advance Beneficiary Notice of Non-coverage, or ABN.

Pay attention to it.

An ABN generally means your provider believes Medicare may not pay for a particular item or service.

The notice should identify what Medicare may not cover, why the provider believes Medicare may not pay, and an estimate of the cost.

Signing an ABN isn’t simply routine paperwork.

It’s giving you important information about potential financial responsibility and choices you have about receiving the service.

Medicare explains Advance Beneficiary Notices and your rights when Medicare may not cover a service.

What you can do: Before signing, ask:

“Why do you believe Medicare may not cover this, and approximately how much could I owe?”

If you choose the option that requires the provider to submit the claim to Medicare and Medicare denies it, you retain the ability to appeal that decision.

6. If You’re in the Hospital, Ask One Very Important Question

“Am I an inpatient, or am I under outpatient observation?”

It may sound like a technical distinction.

It isn’t.

You can be lying in a hospital bed, receiving medications, meals, tests and nursing care — and even spend the night — without technically being admitted as an inpatient.

Medicare considers observation services outpatient services.

Your status can affect how your hospital care is billed and, with Original Medicare, may also affect whether Medicare covers a subsequent stay in a skilled nursing facility.

For traditional Medicare-covered skilled nursing facility care, Medicare generally requires a qualifying inpatient hospital stay of at least three consecutive days. Time spent in observation before you’re formally admitted doesn’t count toward that requirement.

Medicare provides a helpful explanation of the difference between inpatient hospital admission and outpatient observation status.

You can also read Medicare’s requirements for Skilled Nursing Facility care.

What you can do: If you or someone you care for is hospitalized, ask about inpatient versus outpatient status. If the stay continues, don’t be afraid to ask again.

7. Ask What You Should Expect to Pay — Before You Receive the Service

This might be the simplest question on the list:

“What should I expect my responsibility to be?”

An estimate isn’t a guarantee, and there are situations where an exact cost can’t be known beforehand.

But for scheduled, non-emergency care, asking ahead of time may uncover something worth investigating.

Maybe the facility isn’t in your Medicare Advantage network.

Maybe there’s a facility charge you weren’t expecting.

Maybe the service isn’t covered the way you thought.

Maybe the provider doesn’t accept Medicare assignment.

Those are much easier conversations to have before the service than after a large bill arrives.

What you can do: Ask the provider’s billing department for an estimate and verify your benefits with your Medicare plan when appropriate.

The Bigger Medicare Lesson

Choosing your Medicare coverage is important.

Knowing how to use it is just as important.

You don’t need to understand every Medicare billing code or memorize hundreds of pages of Medicare rules. But knowing a handful of questions to ask can make you a much more informed healthcare consumer.

Before your next appointment, remember:

  1. Original Medicare: Do you accept Medicare assignment?
    Medicare Advantage: Are you in-network with my specific plan?
  2. Is this a hospital-based facility, and is there a separate facility charge?
  3. What is included in my Medicare Wellness Visit?
  4. Are there authorization or network requirements for this service?
  5. Why am I being asked to sign an ABN, and what could I owe?
  6. If I’m in the hospital, am I inpatient or under observation?
  7. What should I expect to pay?

Why We’re Talking About This

There are things people don’t always learn when they enroll in Medicare.

We’re going to talk about them.

Not to make Medicare more complicated — but to help you understand the questions to ask, recognize potential problems, and make more informed decisions about your healthcare.

Because sometimes avoiding an unexpected healthcare bill starts with knowing what to ask before the bill ever exists.

Want to Learn More?

The information in this article was verified using Medicare.gov, the official U.S. government website for Medicare.

Additional Medicare resources referenced in this article:

James Bokshan, CLU, ChFC, RHU, REBC

Helping individuals understand their health insurance and Medicare options for more than 33 years.

This article is intended for educational purposes and is not a guarantee of coverage. Medicare rules and individual plan requirements can vary. Always verify your coverage and costs with Medicare, your insurance carrier and your healthcare providers.

Similar Posts