If you are on Original Medicare, a Medicare Summary Notice arrives every three months in which you had a claim. If you are on an Advantage plan or a drug plan, the equivalent is an Explanation of Benefits.
Neither is a bill. Both are statements of what was claimed in your name, and reading them is how most Medicare fraud is actually caught.
The first line to internalise
Across the top it says, in one form or another, this is not a bill. It means it.
You do not pay anything on the basis of this document. If money is owed, a separate bill comes from the provider. What this document does is tell you what happened, so that when the bill arrives you know whether it is right.
What it shows
The notice lists claims processed in the period. For each one you will see who provided the service, what date, what was billed, what Medicare approved, what Medicare paid, and what you may be responsible for.
There is also a section on your deductible status, and a plain-language explanation of any claim that was not paid, with the reason.
At the back there is a section on your appeal rights and the deadline for using them. That deadline is real, and it is one of the reasons to open these when they arrive rather than filing them.
The four checks
Have your calendar or diary beside you. It takes ten minutes.
Did this happen? Go down the dates and services and match them to visits you remember. A date you were away, a doctor you have never seen, or a service you did not have is the thing you are looking for.
Was it once? Duplicate claims for the same service on the same day are a common billing error and a common fraud pattern.
Did you get what was billed? Equipment is the usual problem — a brace, a monitor, supplies. If something was billed and never arrived, or arrived and was never ordered, that is a report.
Does the amount you may owe match the bill you received? If the provider is billing you for more than the notice says, telephone them and ask why, with the notice in front of you.
What to do about a discrepancy
Start with the provider’s billing office. Most discrepancies are ordinary errors — a wrong code, a wrong date, a duplicate submission. A telephone call fixes the majority of them, and it is fair to give them the chance.
If it is not an error, report it. Telephone 1-800-MEDICARE. Have the notice in front of you with the date, the provider and the claim details.
You can also contact the Senior Medicare Patrol in your state. Ohio, Kentucky and Indiana each have one. They are free, they exist specifically to help beneficiaries with this, and they will take the report through with you.
If a claim was denied and you disagree, appeal. The notice tells you how and by when. There is a separate guide on appeals, but the essential points are to start immediately and to keep a copy of everything.
Keeping it usable
Keep the notices for at least a year, with your other Medicare paperwork, somewhere the person who helps you can find it.
A simple habit that makes the ten-minute check almost automatic: keep a page in a diary where you write the date and the name of the practice every time you have an appointment or a test. When the notice arrives, you have something to compare it against, rather than relying on memory across three months.
If you are on an Advantage plan
Your Explanation of Benefits does the same job under a different name and arrives on the plan’s own schedule. The four checks are identical.
Advantage plans also send a separate explanation for drug claims, and those are worth the same attention. Prescriptions billed that were never collected is a real pattern.
Why this matters beyond your own account
Medicare fraud is paid for out of the same programme that pays for your care. Someone billing for equipment nobody ordered is not stealing from an abstraction.
Most of it is found by ordinary people noticing something on a statement that does not match their own memory of their own life. There is no system that does this better than you do, because nobody else knows what you did in March.
Ten minutes, four times a year.
General information, not advice
This guide describes how Medicare generally works. It is not advice about your situation, and rules, dates and figures change — verify anything that matters to a decision against Medicare.gov,1-800-MEDICARE, or your State Health Insurance Assistance Program, all of which are free.
Rights and rules vary by state; this describes Ohio, Kentucky and Indiana. Clearview Medicare Advisers LLC is not connected with or endorsed by the United States government or the federal Medicare program.
Not sure how this applies to you?
Tell us your birthday and whether you are still working. That is usually enough for us to say which periods apply to you and by when. No charge and no obligation.
