If you have Medicare hospital and medical insurance, chances are that you’ve noticed the discrepancies in how long it takes for a claim to be paid out. There are a number of factors that can influence the reimbursement timeline, and understanding these can help you ensure that your claims are filed correctly in order to reduce the pay-out times as much as possible.
What is Medicare?
Before we look at exactly how long does a Medicare claim take, it’s important to understand what Medicare is, and how it works. Medicare is America’s national health insurance program, administered by the Centers for Medicare and Medicaid Services (CMS). It provides health insurance to close to 60 million individuals and covers approximately half of their health expenses with the remaining paid out of pocket, by private insurance or public Part C or Part D Medicare health plans.
How Long Does a Medicare Claim Take and What is the Processing Time?
Medicare Part A and B claims are submitted directly to Medicare by the healthcare provider (such as a doctor, hospital, or lab). Medicare then takes approximately 30 days to process and settle each claim. However, if there are queries or issues with the claim, the process can be a lot longer.
The length of time to process the claim, therefore, depends on first, whether it was a “clean claim” and second, whether it was submitted electronically or on paper.
A clean claim is one that is error-free, properly formatted and contains all the necessary information so that it doesn’t require any edits once it’s in the system. For clean claims that are submitted electronically, they are generally paid within 14 calendar days by Medicare. The processing time for clean paper claims is a bit longer, usually around 30 days.
These timelines are for initial claims. There are often cases where a claim needs to be amended. Examples include the inclusion of late charges, if a diagnosis was omitted, or if the initial claim said the patient went home, but changes were needed because home health services were arranged. For amended or adjusted claims, the process and pay-out times are often shorter, sometimes as little as seven calendar days.
If there are errors in the initial submission, the reimbursement timeline can stretch out for many months whilst the healthcare provider and Medicare iron out the issues.
Does Medicare Pay Out the Claim to the Provider or the Client?
For Medicare Part A claims which relate to inpatient hospital care, skilled nursing facility care, hospice care and skilled home health care, the claims are paid directly to the agency or facility providing the care. The patient is responsible for copayments, non-covered services and deductibles.
For Medicare Part B, which includes doctors’ services, outpatient physical therapy or speech therapy, certain home health care services, medical supplies and equipment, ambulance services and outpatient hospital care, claims may be paid either to you or your provider.
The payer is determined by the assignment. If the healthcare provider accepts assignment, this means that they accept Medicare’s approved amount as full reimbursement for their services. In cases like this, Medicare pays the Part B claim directly to them for the approved amount, and the client is responsible for the remaining 20% (referred to as coinsurance).
If they do not accept assignment, the provider is required to submit the client’s claim to Medicare, and the Part B claim is paid directly to the client. This then makes the client responsible for paying the full Medicare-approved amount, plus an excess charge (which cannot be more than 115% of the Medicare-approved amount).
Who fills out the claim?
In most cases, you won’t need to submit your claims to Medicare for reimbursement, and you will only be liable for cost-sharing payments (coinsurance and deductibles) upfront.
Medicare providers and suppliers are required to send their claims to Medicare, so they will file for reimbursement. The reimbursement rates are set by the Centers for Medicare & Medicaid Services (CMS), and providers are paid according to set guidelines.
For Original Medicare, Part A (hospital insurance) and Part B (medical insurance), Medicare providers send your claims directly, and you will only pay the coinsurance or copayment amount as well as any deductibles. To avoid paying upfront, it’s important to confirm that your healthcare provider accepts Medicare assignments.
When would a client need to fill out a claim?
This should only happen in very rare cases when your claims aren’t being filed by your doctor or supplier in a timely manner. Before submitting a claim, you should approach the healthcare provider to ask them to file the claim. However, if you are nearing the time limit and the claim hasn’t been filed, you can do it yourself. The best way to check whether your claims are being filed on time is to check your Medicare Summary Notice. Additionally, if your health provider isn’t Medicare-assigned, you may have to pay for the service upfront and file for reimbursement yourself.
Any Medicare claims need to be filed within a calendar year of when the services were provided; otherwise, Medicare won’t pay its share.
How do you submit a claim?
You will need to fill out the Patient Request for Medical Payment form (CMS-1490S), and submit it along with:
- The itemized bill from your doctor;
- A letter that explains your reasons for submitting the claim;
- Any supporting documents related to your claim.
For help with submitting a claim, or to answer questions, you can get in touch with a Medicare ombudsman either by contacting Medicare directly or by contacting your State Health Insurance Assistance Program.
What is a Medicare Summary Notice?
The Medicare Summary Notice was previously known as the Explanation of Medicare Benefits, and Medicare sends an MSN form every quarter. It’s not a bill and does not require payment. For Medicare Part A claims, the form will cover the date of service, the number of benefit days used, any non-covered charges, deductibles or coinsurance, and how much you owe. For Medicare Part B claims, the MSN will state the date of service, the services provided, the amount charged by the provider, whether the claims were assigned, how much was Medicare-approved and paid, and how much you owe.
So, in summary, if you’re asking “How long does a Medicare claim take?”, the answer is, “It depends”. Claims processing by Medicare is quick and can be as little as 14 days if the claim is submitted electronically and it’s clean. In general, you can expect to have your claim processed within 30 calendar days. However, there are some exceptions, such as if the claim is amended or filed incorrectly.
To keep on top of your claims, your best point of reference is your Medicare Summary Notice, which will show the status of your claims and allow you to track if any claims haven’t been submitted by your healthcare providers. This is important as you have a calendar year within which to submit your claims. After the year is up, Medicare will not reimburse you.