My doctor says I still owe more
November 10th, 2009 | TriCare Help | Posted by Military Times
Q. My doctor’s bill was $267. I paid him the amount Tricare allowed, $173.82, plus an additional 15 percent. That should have paid his bill in full. Apparently, it didn’t. I am getting bills from them that say “Balance due: $67.10.”
I could pay him that amount, but I don’t think he is entitled to it. I explained to them that I had paid the amount Tricare allowed plus an additional 15 percent. That is what you have explained in your column. I showed them the Tricare Explanation of Benefits so they could see it themselves. They told me this rule applies only to Medicare patients, not to me. Is that right?
The only information I have is what you report in your question. Based on that information, it appears you have paid correctly.
The 15 percent rule is a provision of Medicare law called the Limiting Charge. It says that a nonparticipating provider may charge a Medicare beneficiary up to, but not more than, 15 percent over the amount Medicare approved on the claim.
Congress passed a law applying the Medicare Limiting Charge to Tricare claims beginning Oct. 1, 1993.
But you will never be able to persuade your doctor’s office that you and I are right, and they are wrong. Here’s what you need to do: Write a letter to your Tricare claims processing office at the same address where you submit claims. Explain the situation to them. Attach a copy of the EOB for that claim and copies of the bills you have received.
Tricare will contact the doctor’s office on your behalf and explain the law to them. In most cases, that will resolve the issue. If it doesn’t and the doctor’s office has really dug in its heels, send me another e-mail.
Tags: appeal, claims, doctor, Medicare
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