Medicare billing issues can range from simple coding errors to more complex problems like duplicate billing or charges for services never received.

Resolving these issues quickly is important to protect your benefits and avoid financial hardship.

What Causes Medicare Billing Problems?

Medicare billing issues typically stem from several common sources:

• Coding errors: Healthcare providers use specific codes to bill Medicare for services. Simple mistakes in these codes can lead to claim denials or incorrect payments.
• Eligibility misunderstandings: Confusion about which services are covered under different parts of Medicare (Part A, B, C, or D) can lead to unexpected bills.
• Coordination of benefits problems: If you have multiple insurance policies, determining which one pays first can create billing complications.

Administrative mistakes like incorrect Medicare numbers or birthdate errors can also cause claim denials.

Unfortunately, Medicare fraud does occur, with the Department of Health and Human Services recovering over $4.2 billion from fraud investigations in 2024.

Common Medicare Billing Scenarios

There are several common Medicare billing scenarios one may encounter:

Scenario 1: Denied Claims

A denied claim means Medicare has refused to pay for a particular service or item. Medicare data from early 2025 shows approximately 12% of all initial claims are denied.

Denied claims often result from services not covered by your specific Medicare plan, services deemed not medically necessary, missing prior authorization, or claims submitted after the deadline. When a claim is denied, you'll receive notification through your Medicare Summary Notice or Explanation of Benefits.

Scenario 2: Unexpected Charges

You might receive a bill for services you thought were covered. This typically happens due to confusion about Medicare coverage limitations, services from out-of-network providers (particularly relevant for Medicare Advantage plans), or charges for services that exceed Medicare's approved amount.

These unexpected costs can create significant financial strain, especially for those on fixed incomes.

Scenario 3: Duplicate Billing

Sometimes you might be billed twice for the same service.

This could happen when both your provider and a medical facility bill for the same service, administrative errors cause the same charge to be submitted multiple times, or a previous payment wasn't properly recorded in the system.

Duplicate billing is often overlooked by patients who don't carefully review their Medicare statements, leading to unnecessary payments and depletion of benefits. Regular review of your statements can help catch these errors early.

Scenario 4: Incorrect Coding

Medical services are assigned specific codes for billing purposes. Incorrect coding can result in denied claims, payments that are lower than appropriate, or being charged for more expensive services than you received (known as upcoding).

Coding errors are among the most common billing mistakes and can be difficult for patients to identify without medical billing knowledge. The discrepancies might be subtle but can significantly impact your out-of-pocket costs.

How to Identify Medicare Billing Errors

The first step in resolving billing issues is identifying them. Here's how to spot potential problems:

Review Your Medicare Summary Notice (MSN)

If you have Original Medicare, you'll receive an MSN every three months when you've had services billed to Medicare. This statement shows all services and supplies billed to Medicare, what Medicare paid, and what you may owe the provider.

The Medicare.gov website recommends reviewing your MSN carefully for:

• Services you didn't receive
• Billing for the same thing twice
• Services that were denied but you believe should be covered
• Other errors in service descriptions or personal information

Check Your Explanation of Benefits (EOB)

If you have a Medicare Advantage plan, you'll receive an EOB from your insurance company instead of an MSN. Review it with the same level of attention as you would an MSN, looking for any discrepancies between services received and services billed.

Keep Your Own Records

Maintain a personal health record including dates of all appointments, services received at each visit, names of providers, payments you've made, copies of all medical bills, and prescription information.

The 2025 Medicare Rights Center survey found that beneficiaries who maintained detailed personal records resolved billing disputes faster than those who didn't. This simple organizational step can save significant time and frustration when addressing billing problems.

Steps to Fix Medicare Billing Issues

When you identify a billing problem, follow these steps to resolve it:

Step 1: Contact Your Healthcare Provider

Start by calling your doctor's billing department. Many issues are simple misunderstandings or errors that can be fixed with a phone call.

Explain the issue clearly and have your Medicare card and relevant documents ready. Take notes during the conversation and get the name of everyone you speak with. Ask for a timeline for resolution so you can follow up if necessary.

Most healthcare providers want to maintain good relationships with patients and will work to correct legitimate errors.

Step 2: Contact Your Medicare Plan

If speaking with your provider doesn't resolve the issue, contact Medicare directly.

For Original Medicare: Call 1-800-MEDICARE (1-800-633-4227) or visit Medicare.gov

For Medicare Advantage or Part D plans: Call your plan directly using the number on your membership card

When contacting Medicare or your plan, explain your situation clearly, reference any previous conversations with providers, and ask what specific steps you should take next. Representatives can often help mediate issues between you and healthcare providers.

Step 3: File a Formal Appeal

If the issue remains unresolved, you may need to file a formal appeal. The 2025 Medicare appeals process includes five possible levels:

1. Redetermination by the Medicare Administrative Contractor
2. Reconsideration by a Qualified Independent Contractor
3. Hearing before an Administrative Law Judge
4. Review by the Medicare Appeals Council
5. Judicial review in Federal District Court

For Original Medicare, complete a "Medicare Redetermination Request Form" (CMS-20027) and submit it within 120 days of receiving your MSN. Include a letter explaining why you believe the service should be covered and attach any supporting documentation.

For Medicare Advantage Plans, submit a written request to your plan (some plans have their own forms). Include your name, Medicare number, service in question, and reason for appeal. Follow up within 60 days if you don't receive a response.

Most issues are resolved within the first two levels, with the Medicare Payment Advisory Commission reporting that approximately 32% of first-level appeals were decided in favor of beneficiaries in 2024.

Step 4: Seek Assistance

If you're struggling with the appeals process, help is available:

• State Health Insurance Assistance Program (SHIP): Free Medicare counseling available in every state. Find your local office at shiphelp.org or call 1-877-839-2675.
• Medicare Rights Center: A nonprofit organization that can help navigate Medicare issues through their national helpline: 1-800-333-4114.
• Senior Medicare Patrol (SMP): Helps beneficiaries prevent, detect, and report Medicare fraud. Contact them at 1-877-808-2468 or smpresource.org.

Preventing Future Medicare Billing Problems

Taking proactive steps can help you avoid billing issues in the future. Understanding your coverage is essential - review your "Medicare & You" handbook updated annually, log in to Medicare.gov to see your personalized coverage information, and call 1-800-MEDICARE with specific coverage questions.

Always communicate clearly with providers by verifying that a provider accepts Medicare before receiving services. For Original Medicare, ask if they accept "assignment" (Medicare's approved amount as full payment). For Medicare Advantage, confirm they're in your plan's network.

Keep detailed records by requesting itemized bills for all services, saving all medical receipts, bills, and payment records, and documenting all phone calls related to billing issues.

Special Situations and Solutions

It's important to consider special situations, as well.

Medicare and Other Insurance

If you have Medicare and another insurance plan, make sure all your providers have information about all your insurance coverage and understand which insurance is primary (pays first).

Review the Medicare Coordination of Benefits guide on Medicare.gov for specific situations involving employer coverage, retiree insurance, or other health plans.

Medicare Savings Programs

If you have limited income and resources, you might qualify for Medicare Savings Programs that help pay Medicare costs:

• Qualified Medicare Beneficiary (QMB) Program: Helps pay Part A and Part B premiums, deductibles, coinsurance, and copayments
• Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums only
• Qualifying Individual (QI) Program: Helps pay Part B premiums only
• Qualified Disabled & Working Individuals (QDWI) Program: Helps pay Part A premiums only

The 2025 CMS data shows these programs saved eligible beneficiaries an average of $5,280 annually on healthcare costs. State Medicaid offices can provide information about eligibility and application processes.

Billing Issues with Durable Medical Equipment

Medicare Part B covers medically necessary durable medical equipment (DME) like oxygen equipment, wheelchairs, and walkers. Common billing issues include receiving equipment before getting Medicare approval, confusion about rental versus purchase options, and improper documentation of medical necessity.

Always verify Medicare coverage before accepting any equipment and make sure your doctor submits the required documentation. DME suppliers should provide an Advance Beneficiary Notice (ABN) if they believe Medicare might not cover an item.

Bottom Line

Resolving Medicare billing issues requires patience and persistence. The most successful approach combines:

1. Regular review of all Medicare documents
2. Prompt action when issues arise
3. Clear communication with providers and Medicare representatives
4. Detailed documentation of all interactions
5. Understanding of appeal rights and deadlines

Remember that you have rights as a Medicare beneficiary, including the right to appeal decisions and receive clear information about charges and coverage. By following the steps outlined in this guide, you can successfully navigate Medicare billing challenges and ensure you receive the coverage you're entitled to without unnecessary costs.