Q: When Medicare denies coverage of a service, the Medicare Summary Notice includes an explanation as to why payment is being denied. I don't find those explanations very clear. What is the difference between "Medicare does not cover this service" and "the information provided does not support the need for this service or item?"

A: Understanding your Medicare Summary Notice is of utmost importance. First, of course, it is important that you know what was billed, how much was approved for payment, what Medicare actually paid and what, if any, amount may be your responsibility.

The second reason it is important is that as the user of the billed services, you are the first line of defense in detecting possible Medicare fraud. If your Summary Notice indicates that Medicare is being billed for services or products you did not receive, you should report such discrepancies to Medicare. You can make such a report by simply completing the portion of the notice that allows you to report inconsis- tencies and returning it to Medicare.

You are not the only beneficiary who has had questions about explanations on the Summary Notice. While the two explanations you mention seem, at first glance, to say the same thing, there definitely is a difference in the message that Medicare is providing.

Examples of items not covered by Medicare include dental examinations, routine vision exams and routine screening services such as annual physicals, except for the initial physical examination that is offered to new beneficiaries when they first enroll in Medicare, when no specific medical condition exists requiring such procedures.

For Medicare to cover a service, procedure or product, an existing condition must make it medically necessary. When receiving non-covered services, the beneficiary is responsible for the associated charges.

The message "the information provided does not support the need for this service or item" appears when a service is normally covered by Medicare but is not the appropriate treatment for the particular illness or condition being tested or treated.

Let's use an EKG as an example. Payment will be denied if the condition being treated is the flu. However, if an EKG was billed for someone complaining of chest pains, it would be a covered service with payment approved and paid.

Doctors generally know what Medicare will or will not cover. If it is felt that a particular service will not be covered for a specific reason, the doctor should provide an Advance Beneficiary Notice.

An Advance Beneficiary Notice is a written statement explaining why a particular service for a specific complaint may not be paid for by Medicare. When such a notice is provided, the beneficiary has the option of saying yes or no to the specific treatment. If the beneficiary opts to have the treatment and Medicare denies payment, then the beneficiary is responsible for those charges.

If you receive either type of message and believe that it is in error, you have the opportunity to ask Medicare to review the decision. You might also want to talk with your physician to see if there is more information about that particular service or product that could be provided to Medicare to be used in reviewing its initial decision.

It is most important that you review your Medicare Summary Notice when received to be sure that your healthcare providers are billing Medicare for services that were actually provided to you. Some billing errors are nothing more than simple mistakes, while others could be the result of Medicare fraud. It is your responsibility to make sure that charges billed to Medicare on your behalf are accurate.

If you have signed up for the new Medicare Part D Prescription Drug Coverage plan, you will also be receiving a monthly statement from the provider of your plan. You should review this carefully as it will tell you the drugs that you purchased, what you paid for them, what the plan paid for them and how much in total your drugs have cost.

Make sure that you review these statements carefully and if you don't understand them or disagree with them, then bring it to the attention of the drug plan provider or consult with a HICAP counselor to make sure that you are not being charged incorrectly.

— Betty Berry is a senior advocate for Senior Concerns. The advocates are at the Goebel Senior Adult Center, 1385 E. Janss Road, Thousand Oaks, CA 91362; or call 495-6250. You are invited to submit questions on senior issues.