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What is a Medicare Specialist?

By Vanessa Harvey
Updated May 17, 2024
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A Medicare specialist is someone who has acquired a sound understanding of Medicare, a government insurance offered to residents of the United States. He or she sometimes is referred to as a Medicare consultant. Such a person might work in the medical billing or medical coding department of a private insurance company that is a designated processor of Medicare claims.

Coverage for the services of physicians, hospitalization, prescription medications and durable medical equipment under Medicare is understood by a Medicare specialist who answers questions about coverage for beneficiaries. The national medical insurance for retired persons; those who suffer from end-stage renal disease, or kidney failure; and those who have received disability payments for a period of two years does not cover 100 percent of healthcare costs. When beneficiaries are shopping for additional medical coverage, they often seek out the advice of a Medicare specialist to help them understand what their options are.

Questions regarding Medicare fraud also can be directed to a Medicare specialist who might be familiar enough with the coverage to have an idea of what actions by doctors or hospitals might need to be investigated. The specialist does not necessarily handle the investigation, but he or she knows how to ask the beneficiary enough questions to be able to make a referral to the appropriate office that does. A Medicare specialist sometimes is a customer service representative who represents the government insurance to beneficiaries by telephone and works in a call center.

Such a person also answers questions about eligibility for enrolling in the national insurance and about automatic enrollment, which occurs under certain conditions. A Medicare specialist usually is informed about the various types of preventative medical care that a person should receive in order to help reduce his or her need for long-term or intensive medical treatments. Beneficiaries might be informed by a Medicare specialist about tests that the insurance covers. Other questions that specialists answer include those about automatic premium deductions from a person's Social Security check, special programs for low-income beneficiaries needing help with paying premiums, co-payments and deductibles, as well as questions about beneficiaries' opyions for choosing doctors and hospitals.

Some specialists work or volunteer as consultants at senior community centers so they can serve clients in person and help them to understand the brochures and charts comparing medical plans that supplement Medicare. They also help people take the steps needed to get a second or even a third opinion paid for by Medicare before accepting treatments for a diagnosis that has been made. Complaints about the processing of beneficiaries' medical records also can be shared with a Medicare specialist, who is able to guide patients in the making of an official complaint or an appeals process when coverage is denied.

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