ORIGINAL MEDICARE
Medicare Part B excess charges are not common. Once in a while, a beneficiary may receive a medical bill for an “excess charge.” Doctors that don’t accept Medicare as full payment for certain healthcare services may choose to charge up to 15% more for that service than the Medicare-approved amount. Below, we’ll explain how excess charges work and what you can do to avoid them.
Medicare Part B Excess Charges
Healthcare providers generally accept Medicare assignment. Meaning, they agree with Medicare’s payment terms and rates and bill Medicare accordingly. However, there are a few doctors that may not accept Medicare-assignment and will charge you up to 15% more than the Medicare-approved amount for a specific service. Medicare excess charges are also known as balance-billing.
Today, over 96% of U.S. doctors choose to participate with Medicare and agree only to charge the amount Medicare has approved for the service.
How Medicare Part B Excess Charges Work
Let’s say you visit a nonparticipating podiatrist to get a wart removed from your foot. If the Medicare allowable charge for the procedure is $300, the podiatrist could bill you up to an additional $45. Making the total cost for the procedure $345. If you’ve already met the Part B deductible, your out of pocket costs would be $45 in addition to the 20% coinsurance. 20% of $300 is $60. Therefore, your total out of pocket cost for the procedure would be $105.
How to Avoid Part B Excess Charges
The most obvious way to avoid Part B excess charges is by only visiting doctors who accept Medicare Assignment. The easiest thing you can do is simply ask them if they accept assignment upon scheduling an appointment. You can also use the Medicare.gov physician finder tool to help speed up the process of finding a doctor who participates in Medicare. Additionally, you can supplement your Medicare coverage with a Medigap plan that protects you from excess charges.
What Medigap plans protect you from excess charges?
Two Medigap plans cover excess charges, Plan F and Plan G. Both of these letter plans have high-deductible versions that will also protect you from excess charges.
Medicare Overcharge Measure
The Medicare Overcharge Measure prohibits providers from charging beneficiaries excess charges. Currently, eight states are prohibited from charging excess fees due to the MoM law. If you live in one of these eight states, you’ll never have to worry about excess charges.
What states allow Medicare Part B excess charges?
All but eight states allow Medicare Part B excess charges.
What states do not allow Medicare excess charges?
The Medicare Overcharge Measure prohibits Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, Vermont from allowing doctors to charge excess charges under Part B.
How common are Medicare excess charges?
As stated above, excess charges are not very common. The national percentage of doctors in the U.S. that charge Part B excess charges are only around 5%.
How do you know when a provider charges you an excess fee?
“You normally do not see a bill until after it was submitted to Medicare first. Does that mean I have to ask each doctor I see if he/she accepts Medicare assignment upfront? Also, am I right to say that since I live in NY, providers cannot charge an excess fee?”
You need to ask every provider you see if they accept Medicare assignment. At that time, you will know if you should expect to see an excess charge on the upcoming billing statement. Yes, it is correct to say you don’t have to worry about excess charges if you live in New York.
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I was going to go to a doctor (specialist) that accepted Medicare but they asked for more than the medicare deductible allows. What do I do?
Hi Rosemarie! Your provider should not be asking you to pay the deductible, they should be billing everything through Medicare and allow Medicare to bill you for the deductible on their end. Always tell them to bill Medicare, otherwise, they may not have a record that you met the deductible for the calendar year.