Medicare.gov says you usually pay nothing for Medicare-covered diagnostic lab tests, so a lab bill after a routine visit usually means something wasn't covered. Common reasons are a test Medicare doesn't cover or covers only so often, a routine physical exam (which Medicare doesn't cover), a test without a diagnosis that shows it was medically necessary, or an Advance Beneficiary Notice you signed. Check your Medicare Summary Notice (MSN) for that date before you pay.
Does Medicare cover lab tests?
Medicare.gov says Part B covers medically necessary diagnostic lab tests when your health care provider orders them. These include certain blood tests, urinalysis, and some tests on tissue samples. Medicare also covers some preventive tests and screenings.
For Medicare-covered diagnostic lab tests, Medicare.gov says you usually pay nothing.
If you have a Medicare Advantage plan, your plan may have its own lab copays. Check your plan's Evidence of Coverage.
Why did I get a lab bill after a routine visit?
1. The visit was a routine physical
Medicare covers a yearly "Wellness" visit, which Medicare.gov describes as a conversation-based visit to create a prevention plan. It says the Wellness visit isn't a routine physical exam. If Medicare doesn't cover additional tests or services, like a routine physical exam, you may have to pay the full amount. Lab work tied to a routine physical can fall into that category.
2. Extra tests during a Wellness visit
Medicare.gov says you may have to pay coinsurance, and the Part B deductible may apply, if your provider does additional tests or services during the Wellness visit that Medicare doesn't cover under that preventive benefit.
3. The test isn't covered, or was done too often
Medicare.gov warns that your doctor may recommend services Medicare doesn't cover or covers less often than recommended. Some screening tests are covered only at set intervals. A test repeated too soon may be denied.
4. The diagnosis didn't support the test
Medicare covers diagnostic tests that are medically necessary. If the lab order didn't include a diagnosis showing why you needed the test, Medicare may deny it. It's worth asking the doctor's office to check what diagnosis was sent.
5. You signed an Advance Beneficiary Notice of Noncoverage (ABN)
The Centers for Medicare & Medicaid Services (CMS) says providers, including independent labs, give an Advance Beneficiary Notice of Noncoverage (ABN) when they expect Medicare to deny payment. If you signed one at the lab or the doctor's office and Medicare denied the test, the lab can bill you.
6. Billing mistakes
The lab may have billed before Medicare finished processing, sent the claim to the wrong insurer, or listed the wrong code.
How do I check a lab bill?
- Find the claim on your Medicare Summary Notice (MSN) or Explanation of Benefits. Look for the lab's name and the date your blood was drawn.
- Check "Service approved?" If it says "NO," read the note letter that explains why.
- Check "Maximum You May Be Billed." If the bill asks for more, ask why.
- Look for the test codes. The MSN lists a code in parentheses for each test.
- Find any ABN you signed. It shows which tests were flagged ahead of time.
What should I say when I call?
To the doctor's office first:
"I got a lab bill for tests from my visit on [date]. Medicare denied [test] because [reason on the MSN]. Can you check which diagnosis was sent with the lab order? If it was missing or wrong, can you send a corrected order to the lab?"
To the lab:
"My Medicare Summary Notice shows [test] on [date] with a maximum I may be billed of [amount], and your bill shows [amount]. Can you explain the difference? If my doctor's office sends a corrected order, will you resubmit the claim to Medicare and hold my bill?"
Write down names, dates, and what each office said.