There’s a lot to learn about Medicare Outpatient Services.
A few weeks ago my husband went in for a cardiac catheterization and stent placement. With a stent implant you have to spend an overnight in the hospital. I assumed the hospital stay would be covered under Medicare Part A, but it’s not – it falls under Medicare Part B Outpatient Services.
What is Medicare Outpatient Service?
Medicare outpatient service falls under Medicare Part B. If you are enrolled in a Medicare Advantage plan (Medicare Part C) you should check with your plan to find out what is covered.
Generally, an outpatient hospital service is any type of medical or surgical care performed at the hospital and your doctor does not expect you to be there overnight. There are some procedures that require an overnight stay for observation, but you are not admitted as a patient.
What’s My Out-of-Pocket Expense?
Naturally I was interested in what the hospital was billing Medicare and how much Medicare was reimbursing and how much our copayments would be. Now sit tight, are you ready?
- The hospital sent an invoice to Medicare for $61,415.84
- The Medicare allowed charge is $9,074.83
- Our copayment is $1,969.78
- Medicare denied $128.53 in medication charges
At a first glance you would think your copayment was only 20 percent as the outpatient service falls under Part B, but that’s not the case. As an outpatient, you pay a copayment for each procedure.
Each procedure’s copayment cannot exceed the Part A hospital deductible. There is more cost sharing on an outpatient basis. In my husband’s case there were four procedures all requiring a copayment.
The other charges Medicare denied were charges for over-the-counter drugs or self-administered drugs. These are not covered if you are receiving outpatient services. Medicare advises to check with your Part D provider as they might reimburse in special situations. We are being charged $24.88 for 500 mg of Naprosin (aka Aleve) and $103.65 for insulin which my husband refused because he does not use insulin.
Conclusion
Since outpatient services are generally a preferred method of surgery, I am really surprised there isn’t more information detailing what you can expect to pay ranging from the copayments to your medications.
Medicare Outpatient Services appear to have more cost sharing. Depending on how many procedures are involved you could be paying numerous copayments. Remember if you take any over-the-counter or self-administered medications, they will also be denied by Medicare if the hospital administers them.
The next time we have outpatient services, I’m going to request a cost estimate, bring along any self-administering, prescription medications and over-the-counter medications.
Don’t Ever Forget You Have Rights!
For more information about your rights, the different levels of appeals, and Medicare notices, visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet “Your Medicare Rights and Protections.” You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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