Forms & Policies

Medicare Billing

Fees

Every Medicare patient who is seen in our office is charged using a specific fee schedule. This fee schedule is generated each year by Medicare and is issued in the Fall for the following year. When your visit is completed, you will be asked to pay the Medicare fee schedule charge for the services you received. Our office accepts cash, check, Visa, MasterCard, Discover or American Express. If you cannot pay your charges in full at the time of service, you may speak to a patient account representative to make payment arrangements.

You will be billed the amount known as the “limiting charge.” This represents 115% of Medicare’s “allowable charge” from their fee schedule. When your claim is processed, Medicare will reimburse you at 80% of their allowable charge (after you have met your deductible).

Once You Have Been to Wake Gastroenterology for a Visit

Sometimes your doctor may recommend a procedure or test that may not be covered by Medicare. We will tell you that there is the possibility that Medicare may not pay for the procedure, and you will be asked to sign a Medicare waiver. If Medicare denies payment for these charges, you are responsible for the entire charge. If you have not signed a waiver, you may not be responsible for payment if the denial is upheld on appeal.

Complimentary Crossover

Medicare has an agreement with several insurance companies to automatically forward your claim to a secondary insurance carrier. This results in you receiving your reimbursement from the secondary insurance more rapidly because you don’t have to wait to send in a paper claim. This process is known as “complimentary crossover.” It is your responsibility to contact Medicare to see if your account is set up to automatically forward claims to your secondary insurance carrier.

Claim Forwarded to Private Insurance

If you have Medicare/Secondary crossover set up, when you receive the Medicare summary of benefits, it will indicate that “this claim has been forwarded to your private insurance.” If this does not appear on the summary of benefits, a paper claim needs to be submitted. You should contact WIMC for a printed claim form that you can forward to your secondary insurer.