Medicare Part B is the part of Medicare that covers doctor’s visits and outpatient services. Medicare has a pre-defined fee schedule that most doctors that participate in Medicare use. This is called accepting Medicare “assignment.” Explaining Medicare Part B Excess Charges
However, doctors can choose not to accept that fee schedule and charge more than Medicare allows – these charges, over and above the Medicare payment schedule, are called Part B Excess charges. Explaining Medicare Part B Excess Charges
When you go to a doctor that does not accept Medicare “assignment”, they have the option of “balance billing” above the Medicare payment schedule in most states. If you do not proactively ask the provider if they accept Medicare assignment, you may be surprised to receive a bill after services and after Medicare and your supplement insurance have paid their portions.
This bill will generally come to you 2-4 weeks after your visit to a non-participating provider in Medicare. The “excess charges” amount is limited to 15% above the Medicare-approved amount. Explaining Medicare Part B Excess Charges
Generally, we see these excess charges to occur with much more regularity at specialists as opposed to at primary care physicians.
There are two relatively easy ways to avoid Medicare Part B Excess charges altogether. The first is simply to make sure that you go only to doctors that participate in Medicare (i.e. accept Medicare assignment).
There is not a list of network providers maintained by Medicare, unfortunately. However, you can verify that your provider takes Medicare assignment by simply asking them. Anyone in the billing/insurance office should be aware of this practice and terminology and should be able to answer that question for you. Ideally, you would confirm this before seeing a doctor or receiving services.
The other way that you can avoid the excess charges is to be enrolled in a Medigap (Medicare Supplement) plan that covers those excess charges for you. Most of the more common Medigap plans do cover the excess charges; however, Plan N is one of the plans that does not.
If you have Medicare with a Medigap Plan N, you will still be responsible for the Part B Excess charges if your doctor does not accept the Medicare payment schedule. Other common Medigap plans – such as Plan G and Plan F – do cover the Part B Excess charges. Explaining Medicare Part B Excess Charges
There are a few states which have prohibited excess charges from being executed – currently, these states are: CT, MA, MN, NY, OH, PA, RI and VT.
Nationally, Medicare Part B Excess charges are still relatively uncommon. Recent estimates show that patients get billed for excess charges on less than 5% of claims. Still, it is something that you should be aware of so that you can avoid this unneeded and preventable expense.
Garrett is the founder/President of Secure Medicare Solutions, a leading, independent Medicare insurance agency. Since 2007, Garrett has worked with tens of thousands of people turning 65 or already on Medicare to understand, compare and choose Medicare insurance that fits their specific needs and situation.
His latest project is 65Medicare.org, an online hub for people just starting with Medicare, which is focused on distilling difficult Medicare questions into easy-to-understand resources.
Garrett resides in North Carolina with his lovely wife, Celeste, and three spirited children.View All Articles