Clinic Payment Information for Medicare Patients

The following information should be considered by patients covered by Medicare as primary or secondary payer.

As you may already know, Medicare does not pay for every medical service on every occasion. Medicare has a set of rules to determine if certain tests, services, and procedures can be covered. These coverage rules are based on your medical condition and, sometimes, on the number of times that you have had a particular test, service, or procedure in the past. The fact that Medicare does not pay for something does not mean it is not necessary. For example, you probably know Medicare does not pay for most prescription drugs.

The University of Chicago Medical Center (UCMC) outpatient clinics are obligated to apply the Medicare coverage rules when they bill Medicare. When making appointments or ordering tests, UCMC clinic staff will check the Medicare rules to see if the test, service, or procedure will be covered for someone with your medical condition before you are provided with the service. This will help you to plan.

If, after checking the coverage rules, UCMC clinic staff believes that it is likely that Medicare will not pay for a test or procedure your doctor orders, then our staff will ask you to sign an "Advance Beneficiary Notice" (ABN). The ABN is a form that Medicare requires all hospitals and doctors to use when Medicare does not pay for a service to make sure that patients have a choice about their health care in the event that Medicare does not pay. If we ask you to sign an ABN, you will have two options:

• You may choose to receive the test or procedure, agree to be responsible for payment, and sign the ABN.
• You may choose not to receive the test or procedure, refuse to be responsible for payment, and sign the ABN.

If you are given an ABN, a member of our staff will be available to answer your questions about your financial responsibility and payment options so that you can make an informed decision about your health care.

Please review the additional information below about the ABN process. Your satisfaction is important to us, and our staff is available to assist you through this process. If you have any questions, you can contact Outpatient Services at (773) 702-3384, or ask to see a Finance Representative on your next visit.

Frequently Asked Questions

• How does the outpatient billing process work?
• How does the outpatient coverage process work?
• How will I know if a services is not covered?
• What is the purpose of an Advance Beneficiary Notice (ABN)?
• Why can't the Medical Center tell me definitely whether or not Medicare will cover a service?
• When will I be asked to sign the ABN?
• Will supplemental insurance pay for services that Medicare won't cover?
• If Medicare will not pay for a test, procedure, or therapy does it mean that I do not need it?
• What if I refuse to sign the ABN?
• What if I have questions?

Q. How does the outpatient billing process work?
A. When your doctor orders a test, procedure, or therapy for you at the University of Chicago Medical Center, the Medical Center--NOT your doctor--bills Medicare directly for the services that are provided to you. The Medical Center provides Medicare with your Medicare number, the services (test, procedure, therapy) provided to you, and the diagnosis, or reason, that the services were provided to you.

Q. How does the outpatient coverage process work?
A. Medicare publishes rules that state when a particular test, procedure, or therapy can be covered and paid for. Medicare covers only those services that it has determined are reasonable and necessary to diagnose or treat your medical condition. This is known as medical necessity.

Even if a test, procedure, or therapy is usually covered, coverage of a specific service on a specific day depends on your particular diagnosis or medical symptoms, your age, and sometimes on the number of times that you have received a test, procedure, or therapy in the past. Medicare requires that all hospitals report your diagnosis when claims for payment are submitted. Medicare generally does not pay for screening tests or routine or annual checkups.

Q. How will I know if a service is not covered?
A. The Medical Center will consult the Medicare coverage rules mentioned earlier. If the Medical Center believes that Medicare coverage rules do not allow Medicare to pay for a service, you will be notified and asked to sign an Advance Beneficiary Notice (ABN).

Q. What is the purpose of an Advance Beneficiary Notice (ABN)?
A. The purpose of an ABN is to give you notice--before a service is provided to you--that the Medical Center believes it is unlikely that Medicare will cover the test, procedure, or therapy that your doctor has ordered.

The ABN will list the service, explain why the Medical Center believes Medicare might not pay, and inform you that you will be fully and personally responsible in the event that Medicare does not pay. The ABN will include a place for you to sign and indicate your agreement to pay for the services in the event that Medicare does not pay.

Q. Why can't the Medical Center tell me definitely whether or not Medicare will cover a service?
A. Only Medicare can make a final and official coverage decision. The Medical Center can predict this decision based on Medicare publications about coverage, but only Medicare can make the official determination. The Medical Center can request a coverage decision from Medicare only after you sign the ABN.

Q. When will I be asked to sign the ABN?
A. You will be asked to sign an ABN before the service is performed. Usually, you will be asked to sign an ABN when you arrive at the Medical Center to register. If you are scheduled to receive another service on a different day, you will be asked to sign a separate ABN that addresses that specific service.

Q. Will supplemental insurance pay for services that Medicare won't cover?
A. Supplemental insurance policies (sometimes called Medigap policies) may pay for some services not paid for by Medicare. If you think that your secondary insurance is a Medigap policy, you may ask the Medical Center to bill Medicare for a denial notice. Once Medicare refuses to pay the claim, the Medical Center will bill your secondary insurer.

Q. If Medicare will not pay for a test, procedure, or therapy does it mean that I do not need it?
A. No. Doctors base their decisions on a wide range of factors--including your personal medical history, medications you might be taking, and generally accepted medical practices. Even if your doctor believes a particular procedure is "good medicine" and useful for providing the best care for you, it is possible that Medicare may not consider the procedure to be medically necessary for patients with your diagnosis.

Q. What if I refuse to sign the ABN?
A. If you refuse to sign the ABN and demand the service, you will be held personally and fully responsible for payment.

Q. What if I have questions?
A. If you receive an ABN and have questions, contact your doctor or other healthcare provider or clinic business representative. For further information, contact the director of outpatient services at (773) 702-3384.

Please visit the Medicare Web site for more information on coverage and additional Frequently Asked Questions (FAQ).

More Information

• Online Bill Pay
• Billing FAQ
• Insurance Plans
• Patient Financial Responsibility
• Financial Assistance
• Clinic Payment Information for Medicare Patients