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Is it possible to know the cost of a medical procedure ahead of time?

Medicare
Medicare

Medical expenses can have a significant—and unwelcome—impact on your finances. While keeping track of your health and the costs of treatment might be difficult, the good news is that Medicare will cover a portion of the costs of covered medical care. In addition, by following the procedures outlined below, you can estimate your out-of-pocket expenditures before receiving medical treatment.

What kind of medical care will you get?

Do you have an appointment with your doctor for a normal preventative exam? To diagnose or treat a medical issue, did your doctor prescribe tests, a procedure, or a referral to a specialist? Do you need to go to the hospital for a treatment or a test? The cost of your care is determined in part by the sort of care you receive.

Medicare Part B covers a number of preventive services at no cost to you. For some of these preventive services and screenings, you generally pay nothing for the test as long as the doctor participates in Medicare. These include:

  • A “Welcome to Medicare” preventive visit available during the first 12 months you have Medicare Part B
  • An annual wellness visit
  • An annual screening mammogram
  • A screening colonoscopy
  • An annual Prostate specific antigen (PSA) test
  • Annual flu shots, vaccines to prevent pneumococcal infections such as pneumonia, and shots for hepatitis B (for those at high or medium risk)
  • A yearly visit with your primary care provider to help you lower your risk for cardiovascular disease.

To learn more about your coverage for each type of service and screening, you may refer to the Medicare handbook, Medicare & You.

When it comes to diagnostic care and treatment, determining the cost of proposed care gets more complicated. Prices can vary for the same test or procedure across the country and even within a particular metropolitan area. Furthermore, even your health-care providers do not know precisely what services you may need during or after a procedure. Don’t be discouraged. You can still obtain an estimate about the cost of your planned care.

Inquire about the costs of suggested medical services with the specialists.

Discuss the suggested therapy with your doctor. Request a list of medical services involved with the therapy, as well as a cost estimate. Determine if the therapy will take place at a doctor’s office, a hospital, or an outpatient facility. How much you pay is often determined by where you receive care.
Check with your Medicare plan’s customer service to see if the therapy you’re considering is covered and if there are any restrictions. Some therapies, for example, may require prior authorization to certify the planned treatment’s medical necessity.

Request a price quote from the hospital, ambulatory surgery center, or other medical facility where you will be treated. Typically, your doctor’s rates for services are different from those charged by the institution, so you’ll need to know the costs of both.
An organization determination for the proposed service or treatment can be requested by you, your doctor, or your authorized agent. Your Medicare plan will reply, notifying you of the service’s coverage, the amount you may anticipate to pay, and any service or item quantity limits.

Know your provider’s relationship with Medicare

If you have Medicare Part A and Part B coverage, it’s important to know your provider’s relationship with Medicare because this determines how much you will pay for Medicare covered services.

  1. Medicare participating provider accepts Medicare and takes assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. Your expense would be limited to the annual deductible, if applicable, and the coinsurance or copay amount.
  2. A non-participating provider accepts Medicare but does not agree to take assignment in all cases. You could be responsible for up to 35% of the Medicare approved amount for covered services in addition to any applicable deductible and copay or coinsurance.
  3. An “Opt-out” provider does not accept Medicare at all. This means the provider can charge whatever he or she wants for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You may be responsible for the entire cost of your care.
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