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Part B Excess Charges

June 11, 2017

 

What are excess charges?

 

Medicare beneficiaries may have to pay Medicare Part B excess charges if the receive services form a non-participating provider. A provider that has not signed an agreement to accept assignment for all Medicare -covered services is considered "non-participating." However, these providers can still choose to accept assignment on a case by case basis.

 

Here's what happens if a doctor, provider, or supplier doesn't accept assignment:

 

 The Medicare beneficiary might have to pay the entire charge at the time of service. Their

doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-

covered services they provide to them.

 The Provider can charge them more than the Medicare-approved amount, but there's a limit

called "the limiting charge." The provider can only charge them up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount. 

 

Because the maximum limiting charge is actually only 9.25% more than participating providers can collect, unless the medical provider can collect the limiting charge balance on almost all patients, it may be more profitable for them to become a participating provider In addition, Medicare reimburses the beneficiary directly instead of sending the payment to the non-participating provider. This means that the provider must incorporate additional billing process’s.

 

The vast majority of providers who provide Medicare-covered services are participating providers In addition, some states ban charging Medicare Part B excess charges and require all providers to except assignment on Medicare claims. These states include Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.

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Participating and Non-Participating Medical Providers

June 11, 2017

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This website is a private website and is not associated, endorsed or authorized by the Center for Medicare and Medicaid Services, nor do we claim to be. This site contains basic information about Medicare Supplement insurance for people with Medicare. If you would like to find more information about the Medigap program, please visit the Official US Government Site located at www.medicare.gov.