Medicare Part B First Doctor Visit...What do I pay

[hudson]

I'm new to Medicare; I am on regular Medicare Part B.
If I go to a urologist for a regular office visit, what's my "out the door payment"?

I've Googled much and haven't found an "idiot-proof" answer. I did find this...

"For Medicare-covered services, you must first pay the Medicare Part B annual deductible, which is $140 in 2012.
After you have met your deductible, you pay a Part B coinsurance for Medicare-covered services. For doctors’ visits you generally pay 20 percent of the Medicare-approved amount. For mental health services you pay 40 percent of the Medicare-approved amount." http://www.medicareinteractive.org/page ... ide_id=357

My guess is that the answer is $140.

[mur44]

If Medicare approved amount is greater than $140,
your out-of-pocket expense:
$140 + (Medicare_approved_amount - 140) * 0.20

You are responsible for 20% co-insurance after meeting the
annual deductible.


Disclosure: I am a Certified Volunteer Medicare Counselor from NJ

[hudson]

If Medicare approved amount is
from NJ

Thanks! Where/how does one find the Medicare approved amount? For NC.

[sscritic]

The fully implemented resource-based MPFS amount for a given service can be computed by using the formula below:
MPFS Amount = [(RVUw x GPCIw) + (RVUpe x GPCIpe) + (RVUm x GPCIm)] x CF
Where:
RVUw equals a relative value for physician work, RVUpe equals a relative value for practice expense, and RVUm refers to a relative value for malpractice.

In order to consider geographic differences in each payment locality, three geographic practice cost indices (GPCIs) are included in the core formula:
• A GPCI for physician work (GPCIw),
• A GPCI for practice expense (GPCIpe), and
• A GPCI for malpractice (GPCIm).

The above variables capture the efforts and productivity of the physician, his/her individualized costs for staff and for productivity-enhancing technology and materials. The applicable national conversion factor (CF) is then used in the computation of every MPFS amount.

MPFS = Medicare Physician Fee Schedule

I thought you might enjoy this.

[hudson]

The fully implemented resource-based MPFS amount for a given service can be computed by using the formula below:
MPFS Amount = [(RVUw x GPCIw) + (RVUpe x GPCIpe) + (RVUm x GPCIm)] x CF
Where:
RVUw equals a relative value for physician work, RVUpe equals a relative value for practice expense, and RVUm refers to a relative value for malpractice.

In order to consider geographic differences in each payment locality, three geographic practice cost indices (GPCIs) are included in the core formula:
• A GPCI for physician work (GPCIw),
• A GPCI for practice expense (GPCIpe), and
• A GPCI for malpractice (GPCIm).

The above variables capture the efforts and productivity of the physician, his/her individualized costs for staff and for productivity-enhancing technology and materials. The applicable national conversion factor (CF) is then used in the computation of every MPFS amount.

MPFS = Medicare Physician Fee Schedule

I thought you might enjoy this.

Thanks...that explains it....catch-a-22.
So the only way to find out is to call the doctor's office and ask?

[cheese_breath]

If Medicare approved amount is greater than $140,
your out-of-pocket expense:
$140 + (Medicare_approved_amount - 140) * 0.20

You are responsible for 20% co-insurance after meeting the
annual deductible.

If you have a Medigap plan it will pay some or all of the deductable and co-insurance. It depends on which plan you have. See the link below to compare the different Medigap plans.

http://www.medicare.gov/supplement-othe ... digap.html

[Calm Man]

This brings up a question I was asked and didn't have the answer. Does the doctor's office have immediate online access to the Medicare logs to know if you've met the deductible? Otherwise how do they know what to ask you or do you walk out the door and they bill you (which I know doctor's offices hate doing because of low collections)?

[Tony]

In my experience, once you've met your $140 deductible for the year, if you have a Medicare Supplement policy - also known as a Medigap policy - you will rarely have to pay anything else.

I do have one provider who does not "accept assignment". "Accept assignment" is a Medicare term. It means that the provider can charge 15% above the Medicare approved amount. The one provider I have who does not accept assignment is a GP, so the 15% is a small amount.

Some Medigap plans, like Plan F, will cover that 15%, as well as the 20% coinsurance that Medicare does not cover.

I recommend getting a Medigap plan. Even if it's Plan A, which is what I have, it is good insurance to have. If you have lots of health conditions, or expect to have, then you may want to consider a plan that offers more coverage, and is more expensive. I am familiar with both USAA and Mutual of Omaha. Both have excellent customer service.

[Tony]

This brings up a question I was asked and didn't have the answer. Does the doctor's office have immediate online access to the Medicare logs to know if you've met the deductible? Otherwise how do they know what to ask you or do you walk out the door and they bill you (which I know doctor's offices hate doing because of low collections)?

Some Medigap policies will cover the deductible. My policy does not. The doctor's office finds out after submitting the bill to Medicare (which then sends it to my Medigap provider) that I have not met my deductible, or some portion of it. The doc's office then bills me that amount. This is my experience - other doc's offices may handle it differently.

[pshonore]

This brings up a question I was asked and didn't have the answer. Does the doctor's office have immediate online access to the Medicare logs to know if you've met the deductible? Otherwise how do they know what to ask you or do you walk out the door and they bill you (which I know doctor's offices hate doing because of low collections)?

In order to even know if you're subject to a deductible, they have to know which Medigap plan (if any) you have since at least one plan pays the deductible. I've never been asked for a co-payment and as a result they bill me after Medicare and Medigap pay their portions.

[Hexdump]

In my experience, once you've met your $140 deductible for the year, if you have a Medicare Supplement policy - also known as a Medigap policy - you will rarely have to pay anything else.

I do have one provider who does not "accept assignment". "Accept assignment" is a Medicare term. It means that the provider can charge 15% above the Medicare approved amount. The one provider I have who does not accept assignment is a GP, so the 15% is a small amount.

Some Medigap plans, like Plan F, will cover that 15%, as well as the 20% coinsurance that Medicare does not cover.

I recommend getting a Medigap plan. Even if it's Plan A, which is what I have, it is good insurance to have. If you have lots of health conditions, or expect to have, then you may want to consider a plan that offers more coverage, and is more expensive. I am familiar with both USAA and Mutual of Omaha. Both have excellent customer service.

I too recommend getting a medigap policy. I was surprised in that I have to yet make any kind of payment at the doctors office.
I am new to it this year and it is with New Era and costs $140.00/month.

[hudson]

I'm new to Medicare; I am on regular Medicare Part B.
If I go to a urologist for a regular office visit, what's my "out the door payment"?

I've Googled much and haven't found an "idiot-proof" answer. I did find this...

"For Medicare-covered services, you must first pay the Medicare Part B annual deductible, which is $140 in 2012.
After you have met your deductible, you pay a Part B coinsurance for Medicare-covered services. For doctors’ visits you generally pay 20 percent of the Medicare-approved amount. For mental health services you pay 40 percent of the Medicare-approved amount." http://www.medicareinteractive.org/page ... ide_id=357

My guess is that the answer is $140.

I'm the OP.
I called the urologist's office and got answers.

If straight Medicare Part B: $99
But because Medicare is primary and my state retiree insurance is secondary, I'll pay the $70 specialist co-pay.

[Alan S.]

Since the deductible is a CY deductible, if you can wait 3 1/2 weeks, you will eliminate the 2012 deductible. While the 2013 deductible is slightly higher, it's pretty sure that you will be paying the deductible anyway before 2013 is done.

You might also look into the Welcome to Medicare one time free exam, particularly if you still are entitled to it if you visit a specialist first. The other new Medicare annual wellness exam is a farce. You and the MD are restricted to a narrow check list, and if you ask any questions or get any advice you get billed for an office visit anyway. I think the one time Welcome visit is broader to some extent.