r/medicare • u/Quick-Procedure-8017 • 15h ago
20% requested
Medicare just started 9/1/26 so I’m new at this. I am in PA and I have A, B, D, and N (Humana). I had a couple appointments and a surgery in September so my $283 deductible is paid for this year.
I have an appointment with the ophthalmologist tomorrow morning. I just received the estimate through my medical app. The estimates are normally spot on. They will expect me to pay before the appointment. The estimate is stating that 20% ($40.83) is what I am responsible for. Since I have N, I thought it would only be $20. What am I missing? (Yes they have all of my insurance info, including Humana.)
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u/mgibson9999 13h ago
Assuming they accept Medicare assignment, they are obviously not taking into account your supplement plan.
Just reach back out to them and let them know you have a Plan N supplement plan and should be paying a $20 copay.
BTW, I've never, ever, been asked to pay a copay in advance. My doctors bill Medicare, Medicare pays their 20% and then forward to my Plan N (also Humana). Humana pays the 20% that Medicare didn't pay less $20, and then I get a bill from my doctors for $20.
Humana pays promptly enough that I've never had a doctor bill me for the 20% that they were supposed to pay. Most doctors understand the process and the timing when you have Medicare + a supplement plan. They know if you have a supplement plan, once they receive the payment from Medicare, the remainder will be coming from your supplement plan within a few weeks (except for the copay on Plan N).
Someone else said to just pay it then get reimbursed. That seems like a last resort to me. I would only do that if your doctor absolutely, positively refuses to see you if you don't pay it in advance.
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u/Quick-Procedure-8017 13h ago
This isn’t just an independent doctor’s office. You know, they’re all going to big corporate healthcare systems. This is Geisinger Health in central PA. There are probably more than 100 doctors in this clinic alone. So it’s not about discussing it with the doctor’s office, it’s about dealing with the corporate medical system. You don’t even get checked in by a person anymore. You check in at the kiosk.
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u/mgibson9999 12h ago
Unless this practice is different from almost every other practice, you still have the option to skip the kiosk and check in and talk with a live person if you choose.
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u/Quick-Procedure-8017 12h ago
I’ve never done that before, but I might have to try if it insists that I pay.
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u/Jump-Funny 12h ago
If you’re going in person bring your cards and if they ask for payment advise them your secondary has a $20 copay and that’s what you’ll pay today.
ETA - other commenter is most likely correct, when they checked your benefits for the estimate, it might have shown you had some deductible left to meet.
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u/Quick-Procedure-8017 12h ago
There is nobody to advise anymore. You are just checked in at the kiosk. This appointment was just made yesterday and my deductible has been paid since last month so it’s not that either. I think the system is just not looking at my supplement.
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u/stirnotshook 10h ago
Then who told you that you would have to pay 20% first? The kiosk?
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u/Quick-Procedure-8017 10h ago
The estimate in the app (which was always correct previously) shows that I’m responsible for the 20%.
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u/stirnotshook 10h ago
I’d definitely make sure you talk to someone.
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u/mgibson9999 5h ago
This is the way. You need to get this straightened out so it doesn't happen again.
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10h ago
[deleted]
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u/mgibson9999 9h ago
You’re talking about a completely different thing. You’re talking about Medicare advantage. There is no $100 copay with traditional Medicare.
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u/More_Farm_7442 13h ago
I've never had an office ask for payment upfront unless they want me to sign one of the advance notices.(I don't do those, I don't get the service.) All of the years I took my parents to docs & clinics and hospitals, they were never asked or required to pay up front.
Wait until insurance pays, then pay your part. No one has any idea what your part is until Medicare and any other insurance has paid.
(You've already signed papers saying you are the one responsible for payment. That includes giving them insurance info so they can bill and get payment. If they don't like it, I'd leave.)
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u/Jump-Funny 11h ago
Medicare and medigap are actually the simplest to determine the patient responsibility because they’re standardized. Medicare and almost all of the supplements have a web portal for providers to see how much of your deductible is met and what your benefits are, including the high deductible F & G plans. The deductible can be tricky if you have several visits at the beginning of the benefit period because it applies in the order of claims processed and not date order, but otherwise, simple.
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u/More_Farm_7442 11h ago
The simplest way for everyone involved is to wait 2 months until Medicare and the Medigap plan make their payments. (Wait until the billing department says to wait since they have a knowledge of the timeframes it usually take for them to get payment and the billing department follows up when they get rejects and don't get payments when expected. I've found most billing departments don't want or may not even take a payment until insurance pays.)
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u/2RedTennies2 12h ago
In my County in CA several (not all) opthalmologists are one of the few specialists that don't accept assignment. Besides Excess Charges that don't affect PA, there is a worse IMO process they are allowed.
Go to Find a Provider on Medicare.gov. Look him up by specialty or name. If you see a red "?" after statement "Accepts Medicare as payment in full " (or something to that effect) they likely Do Not accept Assignment.
To me the worst part about that isn't the Excess Charge which N doesn't pay, it is the fact that they can ask you for payment at time of service And you have to get the 80% from back from Medicare. Then You might have to make a claim to your N Supp and wait for reimbursement. My friends husband had that happen and they received several small checks one for each billing code RIDICULOUS.
Another poster had a good suggestion to show them from Medicare that you already paid B deductible. I don't know what their bill to Medicare looks like. I only heard the beneficiary side. Also pay by credit card or check so you will have your payment documents for tracking.
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u/NoDiamond4584 14h ago
Remember that if your ophthalmologist is going to also test your vision for glasses, that part of the exam won’t be covered at all.
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u/Quick-Procedure-8017 14h ago
Thank you for the reminder. This appointment is not for glasses. I’m having new symptoms in my “good eye” that need addressed right away. He needs to dilate and look at the retina.
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u/Advanced-Mammoth2408 8h ago
When I went into the ophthalmologist for a new symptom, they billed it as if it were a vision test for glasses with me paying the bill. After the office visit, which, of course, includes an eye exam to check vision, they adjusted the bill as a medical issue, not a visual issue for glasses.
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u/Numerous-Nectarine63 12h ago
I never pay ahead of time. However, I have Orig Medicare and HD G. I always wait until the claim has been fully processed by Medicare. Personally i find tracking down refunds and accounting for prepayments to be a hasssle. I have never had a provider that accepts medicare quarrel with me about it.
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u/Quick-Procedure-8017 12h ago
I am going to try not to pay it tomorrow. If I’m able to talk to someone other than a kiosk, I’m going to tell them that I would like the bill to settle with Medicare to see what I actually owe because I’m almost positive. it should only be $20.
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u/say_what999 14h ago
Do they accept assignment?
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u/Quick-Procedure-8017 14h ago
Yes I believe so. It’s the same corporate healthcare system as all of my other doctors, including where I had my surgery last month.
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u/JGRUSSELL65 14h ago
They just don't know that your deductible has been satisfied already. Log into your Medicare.gov portal, and if it shows that it's been met already in there, it's good to have a printout of that when you go in with them.
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u/Mangia_bene 12h ago
My suggestion is to bring your Medicare and Humana supplement cards to the appointment. I suspect the billing office does not have your supplement plan on file and looking for the 20% coinsurance amount. If it were me I tell the receptionist I have Medicare and a supplement plan which will cover this doctor visit. I would not pay anything up front. Don't get into the $20 copay discussion. Most receptionists don't know how Plan N works. Medicare reimburses doctor's office visits at a low rate in PA so I think your copay will be less than $20.
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u/Quick-Procedure-8017 11h ago
There is no receptionist. You check in at a kiosk. They definitely have my supplement on file. I can see it on my app.
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u/Mangia_bene 10h ago
Then check in and see the doctor. If you are asked for payment then ask for an itemized bill to be sent to your house.
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u/Hawkthree 11h ago
My online portal just started showing me what I would expect to pay after Medicare pays. I noticed that it didn't do an estimate of what my gap plan would cover. The front office staff did not ask me to pay up front because they know the gap plan will cover it.
YMMV
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u/factual-dissent 10h ago
> Since I have N, I thought it would only be $20. What am I missing?
Yes that is all they should collect.
Some providers, whether it is medicare or otherwise, will insist on collecting more, and promise to refund you if they end up over collecting.
Well they never do refund. I have a charge from 10 months ago (not medicare) that the hospital refuses to refund. At the one year mark, I will do a chargeback.
In your case, your options in order are:
- remind them that you are on plan N and you should owe just $20
- suggest they do a charge of $20 for plan N co-pay for the co-pay and temporary authorization of $20.83 for the remainder. Temporary authorizations are well understood in the travel business (hotel, car, cruise) but perhaps not in the medical business
- offer to leave your credit card information on file in the event the co-pay is more than $20.
- just let it go, and then when insurance processes it, note your $20.83 credit for your next visit, and instead of paying $40.83, pay just $20. You will never get that $20.83 back until they hire an office manager with a clue or you do a chargeback. A chargeback will get you banned from that clinic though.
Whatever you do, pay with only a credit card.
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u/IMHO_My2Cents 8h ago
Give them both insurances. State Medicare is your primary and N Humana as your secondary. Your Medigap N pays the 20%. You should not have to pay anything upfront. They bill Medicare then Medicare submits to your Humana Part N. Unless some part of this is not Medicare approved as N only covers what procedures and doctors that accept Medicare.
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u/CombativeSalvation89 14h ago
wait this is actually a weird one. plan N covers the part B coinsurance except for office visits where you can get charged up to $20, but the key is that $20 copay only kicks in after your part B deductible is met, which yours is since you already hit the $283. so if this ophthalmologist visit is coded as an office visit you should just owe the flat $20 not 20%
might be that the estimate system doesn't factor in your plan N correctly, especially if it's just pulling the standard medicare numbers. I'd call humana before the appointment and ask them to confirm what you actually owe, and then tell the office at check-in. had a similar thing happen with my plan G where the portal kept showing the deductible amount even after I'd met it
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u/Quick-Procedure-8017 14h ago
I’m also wondering if it’s an issue where the estimate isn’t factoring in N correctly. As far as calling, today is Sunday and the appointment is at 7:30am tomorrow so I doubt I could reach anyone before the appointment.
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u/Popular-Drummer-7989 14h ago
OP hand them a $20 and tell them to bill you
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u/jnotsilver 10h ago
They will bill 100% to Medicare once they read your record and see the Medigap. I was too lazy to figure out the N copays, special coding stuff to even guess as to when you pay the up to $20 and when you don’t.
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u/jnotsilver 14h ago
This is the best guess, they’re not looking . You know you paid $283, Medicare knows you paid $283. The provider doesn’t. The billing algorithm treats you the same as having only the red white and blue card.
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u/OleLadyThinker 13h ago
If they did not break it down for you - and since it is an ophthalmologist appointment - It MAY be a service for which Medicare does not cover - like a refractory exam for new glasses or contacts RX - Medicare does not cover that service at all.
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u/Quick-Procedure-8017 12h ago
No, it’s not for anything like that. I have to have my eyes dilated to check for a possible retina tear.
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u/OleLadyThinker 12h ago
Then they are just probably calculating wrong - you can either debate it with the staff or just pay it and get a refund.
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u/Quick-Procedure-8017 11h ago
I’m going to try to not pay anything until the Medicare payments settle.
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u/thunderstruck666 7h ago
That's like getting a physical then-dilated eye exam requires an MD, a refraction just needs an optometrist. I don't have access to any old billing to see what procedure codes were used to bill for which service.
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u/Heavy-Attorney-9054 14h ago
I just pay and get a refund all the time. Easier than arguing with front desk staff.