Medicare
excess charges could mean a surprise doctor’s bill
by Beth Braverman ,
Considerable
Staff | May 31, 2019
You might think that
once you’re on Medicare picking a doctor that takes your insurance and paying
the bills gets simpler. Think again. Even on Medicare you could owe more than
you expect for your care, and the culprit is a something called Medicare Part B
excess charges.
Medicare Part B
excess charges are the difference between how much a doctor charges for a
treatment or procedure and how much Medicare has agreed to pay for it. As a
patient, you have to pay Medicare Part B excess charges out-of-pocket, unless you have
a Medicare Supplement (Medigap) plan that covers those bills.
The good news is that
while Medicare Part B excess charges could add up quickly, actually owing them
is fairly uncommon. And you can avoid excess charges altogether by sticking
with doctors who’ve agreed not to charge them, or by purchasing the right Medicare
Supplement insurance plan.
Just as with the rest
of Medicare,
however, understanding Medicare Part B excess charges can be tricky. Here’s
what you need to know.
Why not all doctors
bill for Part B excess charges
Doctors who accept
Medicare fall into one of two categories: participating and
non-participating.
Non-participating
doctors could charge up to $1,150 for the same service. Medicare would still be
good for $800, but you’d be responsible for the remaining $350.
The vast majority of
physicians who take Medicare are participating and therefore “accept
assignment,” which means that they agree to charge the Medicare-approved amount
for their services. If you are treated by a participating doctor, preventive
services are free, and you’ll owe 20% of the cost of all other care.
Non-participating
providers can decide on a service-by-service basis whether or not to accept the
Medicare-approved payment amount. If they don’t, they’re allowed to charge you
as much as 15% more than the approved amount for your care.
How Medicare Part B
excess charges can add up
If you see a
non-participating provider, you’re on the hook for the coinsurance and
deductible, plus the excess charges, unless you have a Medicare Supplement
policy that pays the difference.
So, for example, if
Medicare has assigned $1,000 to a particular service (based on its typical cost
and your location), with a participating doctor Medicare would pay the
physician $800, assuming you’ve hit your Part B deductible, and you’d pay the $200 coinsurance.
But the tab can be
far worse. In the case of a serious health care condition or medical crisis,
bills for $10,000 or $50,000 or worse could easily carry excess charges in the
thousands.
Plus, suppliers of
medical devices and equipment can levy Medicare Part B excess charges—but
they’re not limited to the 15% cap. And Medicare does not place an annual
ceiling on your out-of-pocket spending.
How to know if you’re
at risk of paying more
Some states require
that all doctors who take Medicare “accept assignment,” or promise not to
charge more than the agreed-upon rates. If you get care in Connecticut,
Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or
Vermont, your doctor cannot bill you for Medicare Part B excess charges.
If you’re not in one
of those states, the easiest way to find out whether you may owe Medicare Part
B excess charges is to ask your doctors whether they accept assignment. If they
do, you’re in the clear.
You can also use the Physician
Compare tool at Medicare.gov to look up whether any doctor in the
country accepts Medicare assignment, as well as whether he or she accepts
Medicare-approved payment amounts.
How Medicare
Supplement plans can help cover the excess charges
If you end up seeing
a non-participating doctor, you can offset your out-of-pocket costs with a Medicare Supplement plan.
Looking for Medicare
Plans?
Look no further. See plans and quotes
here
Show Me Plans
These plans, which
are offered by private insurers, come in 10 varieties and are standardized
across most states (excluding Massachusetts, Minnesota, and Wisconsin).
So the coverage you
get with any Medicare Supplement Plan G policy, for example, will be
identical to what you’d get with any other, although your monthly premium could
vary by provider. (That premium, which is charged by the insurance company, is
on top of the Medicare Part B premiums you owe.)
It’s important to
choose the Medicare Supplement option that’s best for your healthcare needs—and
your budget
Buying a Medicare
Supplement plan that covers Medicare Part B excess charges may be a smart idea
if you know that your current doctor or hospital doesn’t accept assignment. It
may also make sense if you want the flexibility later to see doctors that don’t
accept Medicare-approved amounts.
Medicare Supplement
plans F and G cover 100% of Part B excess charges. With a Plan F, you’ll pay
higher premiums than you would with Plan G, but the plan will also cover the Part B deductible
($185 in 2019). Part F, currently the most popular Medicare Supplement plan, is
scheduled to be phased out starting in 2020.
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