My first checkup on Medicare was billed to me at full boat. I did the legwork, and found Medicare has three codes: “welcome to Medicare”, “first annual checkup”. and “subsequent annual checkup”. The doc had coded for “subsequent annual checkup”, which was rejected, because there had been no billing for the “welcome” visit, or the “first annual”. So, I went back to the doc’s office and barked at them. They rebilled, under the “first annual” code, which, of course, was rejected again. I finally found a web site that spelled out when each code is to be used, so simply and clearly, that even a doctor could understand. Printed out that diagram, and gave it to the clerk at the doc’s office. She exclaimed “I never saw anything like that before” and gave it to the doc. That time, they billed correctly, and Medicare paid.
Some years later, the doc decided I was a candidate for a test, that Medicare pays 100% for. They coded it wrong, and I got a bill. I barked at them, so they resubmitted, with the right code. I got another bill. I called Medicare, asking why they didn’t pay 100%. The Medicare agent used a term along the lines of “assumed payment”, meaning they assumed the doc coded it correctly, and paid what Medicare would pay under that code, and they considered the case closed.
Steve