Frequently Asked Questions:Medicare Questions


What is the purpose of an Advance Beneficiary Notice (ABN)?

Medicare has established guidelines to ensure that all tests or procedures performed on Medicare beneficiaries are medically necessary.

When your physician writes an order for a test, he or she includes the diagnosis or reason for the test on the order. After the test is completed, we will bill Medicare for payment. Medicare requires that all claims submitted on behalf of a Medicare beneficiary include the type of test and the medical reason for the test. If the diagnosis does not meet Medicare’s established criteria for medical necessity, payment for the claim will be denied.

As the provider of care, it is our responsibility to notify our patients prior to testing if the diagnosis supplied by the physician does not meet Medicare’s medical necessity guidelines. In these cases, you will be asked to sign an Advance Beneficiary Notice acknowledging that you are aware that Medicare may not pay the claim and accept financial responsibility for payment.


Why am I asked to complete a Medicare Secondary Payer Questionnaire?

Medicare requires that medical care providers obtain certain types of information from Medicare beneficiaries each time a test or procedure is performed.

Your responses to the questions are used by Medicare to ensure appropriate assignment of payment liability. In other words, Medicare should not be billed for charges that may be the responsibility of another payment source. For example, if you were seeking treatment for an automobile accident, any accident insurance would need to be billed prior to billing Medicare.

Some of the information collected on this questionnaire is maintained in your permanent Social Security record, and each claim submitted on your behalf is matched to this record. We understand that answering these questions each time you are treated can be an inconvenience; however, it is extremely important that we adhere to Medicare requirements and that we submit the most accurate information available.

We appreciate your assistance and understanding as we endeavor to comply with Medicare’s claim requirements.


Is there some place that I can find additional information concerning my coverage by Medicare?

Yes, you can call 1-800-MEDICARE or visit www.medicare.gov to get help with your Medicare questions.


If Medicare does not pay for a test, does that mean that I do not need the test?

No. Your physician bases decisions about testing on a wide range of factors, including such things as your personal medical history, any medications you might be taking and generally accepted medical practices. Even if your physician believes a test will provide useful information to give you the best care, it is possible that Medicare may not consider the test to be medically necessary for your diagnosis.


Why am I billed for some of the medication I am given while receiving services at the Hospital as an outpatient?

During the course of your outpatient treatment, you may be given medication that is considered self-administered by Medicare. Medicare defines self-administered drugs as medications that the patient could, in another setting, take by himself or herself. The list of medications includes tablets, sprays, drops, inhalants and some injectable drugs.

In order to remain compliant with Medicare regulations related to the billing of these drugs, medical providers are required to submit these self-administered drugs as non-covered items on our billing to Medicare.

You will receive a bill from us following payment of our claim by Medicare. In addition to any deductible and co-insurance due, this bill will reflect the charges for unpaid self-administered drugs. Payment for non-covered items will be expected from you. With few exceptions, most secondary insurance carriers do not cover self-administered drugs.

Elmhurst Memorial Healthcare Network

This site is part of the Elmhurst Memorial Healthcare network of Web sites, which covers a variety of topics using the same philosophy: When it comes to medical care, we know that you have a lot of options. And we want you to know that you're more than a patient to us. You're an individual. We would appreciate the opportunity to provide you with state-of-the-art medical care and down-to-earth, personalized attention.

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