Last updated by BillFighter · Checked against Medicare.gov and the federal rules for providers that take Medicare
Six rules, in plain words, with every term explained the first time it comes up. Nothing here tells you which plan to pick. It tells you what the paper in your hand means and what you can ask for.
A hospital that takes Medicare bills Medicare first. That is the deal it signed. Your share does not exist yet; it is whatever is left after Medicare decides. “Can you pay today?” at the registration desk, before Medicare has seen the bill, is an ask, not a rule. Say it back, in writing if you can: “Please bill Medicare and send me the statement once it is processed.”
The hospital can ask. It can give you an estimate. It cannot make paying your share up front a condition of being admitted. That rule is for hospitals; a doctor’s office, a surgery center or an imaging center can collect at the visit. In an emergency, screening and stabilizing come before any talk about money. If a hospital insists, ask for the patient advocate, and then call 1-800-MEDICARE.
On Original Medicare, the Medicare Summary Notice is the statement Medicare mails you every three months in which you had a claim. It says “this is not a bill” on it, and it is not. It is the answer key: what each provider charged, what Medicare approved, what Medicare paid, and the most you can be billed. The only number on a bill that should match it is the last one.
On a Medicare Advantage plan, the plan processes the claim instead of Medicare, and the plan’s own statement is the paper to compare against. Same idea, different sender. Keep every one of these. A hospital in a city you have never been to, or a provider you never saw, shows up on this paper first.
Assignment means the provider agreed to take Medicare’s approved amount as payment in full, so you owe only your deductible and coinsurance. A provider that takes Medicare but does not accept assignment can bill you a capped amount above the approved rate; the cap is printed on your Summary Notice. A provider that has opted out of Medicare has you sign a private contract first, and Medicare pays nothing toward it. The provider search on Medicare.gov shows “accepts assignment” on every listing. A supplement plan may cover the amount above the approved rate; an Advantage plan has its own network rules. Emergency care has its own rule.
A hospital-owned practice sends two bills for one visit: one for the doctor, one for the building. That second one is the facility fee, and your copay only covered the doctor. It is legal; the fight is about being told. Ask before the visit: “Is this office hospital-owned? Is there a facility fee?” On your Summary Notice it shows up as two claims for one date, one marked hospital outpatient.
Compare the receipt from the visit against your Summary Notice or your plan’s statement. Different numbers? Money collected from you that you did not owe has to come back to you, but most offices park it as an account credit and wait. One letter: “Please refund the overpayment of $__ by check within 30 days,” with the receipt and the notice attached, by certified mail. Say “check,” not “credit.” A credit is their money until you spend it there.
Medicare Advantage is instead of Original Medicare, not on top of it. The plan that “picks up the rest” is a supplement (a Medigap plan), and a supplement only works with Original Medicare; one cannot legally be sold to someone on Advantage. Advantage brings its own network, its own prior approvals, its own yearly cap. Which one is right for you is a question for SHIP, the State Health Insurance Assistance Program: free counselors in every state, not paid by any plan. shiphelp.org, or 1-800-MEDICARE.
One more: hospital financial assistance applies after Medicare pays.
A nonprofit hospital is required by federal law to have a financial assistance policy. It is based on income, and it can cover what is left for you after Medicare or your plan pays. Ask for the application in writing. You usually have 240 days from the first bill. The charity care rule →
Have a bill and the Summary Notice that goes with it? Upload both. BillFighter compares them, shows where they disagree, and writes the question.
Check your bill — freeThe check is free. The letter is the paid part: you print and mail it yourself, or we send it by certified mail for you. No account needed to start.
The statement Original Medicare mails you every three months in which you had a claim. It is not a bill. It lists what each provider charged, what Medicare approved, what Medicare paid, and the most you can be billed. If you are on a Medicare Advantage plan, the plan sends its own statement instead, and that is the paper to compare your bill against.
A hospital that takes Medicare can ask for your share up front and can give you an estimate. It cannot make paying first a condition of being admitted. Doctor's offices, surgery centers and imaging centers are different and can collect at the visit. In an emergency, the hospital has to screen and stabilize you before any talk about money.
That the provider agreed to take Medicare's approved amount as payment in full, so you owe only your deductible and coinsurance. A provider that takes Medicare but does not accept assignment can bill you a capped amount above the approved rate, and the cap is printed on your Summary Notice. A provider that has opted out of Medicare has you sign a private contract and Medicare pays nothing toward it.
Because the office is owned by a hospital. A hospital-owned practice bills once for the doctor and once for the building; the second bill is the facility fee, and your copay only covered the doctor. On your Summary Notice it shows as two claims on one date, one marked hospital outpatient. Ask before the visit whether the office is hospital-owned and whether there is a facility fee.
No. A credit is their money until you spend it there. If you paid at the visit and the Summary Notice says your share was less, ask in writing for the overpayment to be refunded by check, with the receipt and the notice attached. Money collected from you that you did not owe has to come back to you.
No. Advantage replaces Original Medicare; it is instead of, not on top of. The plan that "picks up the rest" is a supplement (Medigap), and a supplement only works with Original Medicare. A supplement cannot legally be sold to someone on an Advantage plan. Advantage plans bring their own network, their own prior approvals and their own yearly cap.
That is a question for SHIP, the State Health Insurance Assistance Program: free counselors in every state who are not paid by any plan. Find yours at shiphelp.org or call 1-800-MEDICARE. BillFighter does not recommend plans.
This is the general rule, in plain words. BillFighter is not a law firm and does not give legal advice. If you have been served with court papers, that is the day for a lawyer or legal aid. Nothing on this page recommends a Medicare plan; for that, SHIP.