The aging population faces a number of challenges, and one of the most challenging problems is navigating the Medicare system. In some cases, seniors can incur excess charges with Medicare Part B. 

But what are these excess charges? According to Boomer Benefits, Medicare Part B Excess Charges are a common occurrence. Healthcare providers and physicians decide whether or not they want to participate with Medicare. Doctors and providers who participate with Medicare will only charge you the cost approved by Medicare. This payment is made by Medicare. However, if the amount owed is above what Medicare will pay, you are responsible for the outstanding balance.

Participating doctors will “accept” the balance paid by Medicare as the full payment for services. This is called Medicare Assignment. Medicare Assignment is a program in which doctors accept Medicare payment as a patient’s full payment for services. As a result, you will not receive a bill asking you to pay for charges that go above what Medicare pays for. 

However, practitioners who do not participate with Medicare have the right to request payment for services and can charge you more than 15 percent above the amount covered by Medicare. This excess charge of 15 percent is referred to as a Part B excess charge. This cost comes out of your pocket. However, you do not need to pay excess charges if you possess a Medigap plan with benefits for excess charges under Medicare Part B. 

If your doctor does not accept Medicare Assignment, you will be billed the full amount for services. 

If you want to avoid excess charges, you may want to pick a medical provider that participates with Medicare and will not require you to pay excess charges. There are other benefits to having a doctor who participates with Medicare. These doctors only require that you pay your coinsurance payment or deductible when services are rendered.

The majority of doctors will only bill you after Medicare has paid its predetermined amount. Providers who do not participate with Medicare, however, will charge you the full amount when services are provided. These providers need to “submit your claim to Medicare.” This costs you nothing. Providers who do not participate don’t bill Medicare. As a result, you have to submit the claim on your own, if you want to be reimbursed. Doctors cannot charge a fee for submitting claims.

Essentially, a Medicare Part B excess charge is a fee you are charged if your provider is a nonparticipant and does not accept Medicare Assignment. If you are on Medicare Part B, it is important to understand how Medicare Part B excess charges will impact you. Healthcare providers and doctors have the ability to charge you much more than the amount Medicare covers. This is the Medicare Part B Excess Charge.

A nonparticipating provider has the ability to put excess charges on your bill. If your doctor does not accept Medicare Assignment, he or she can charge you hundreds above what Medicare already pays for in a given calendar year. 

There may be cases where you see a doctor who participates with Medicare but does not accept claims for services rendered. However, if you are assigned an Advanced Beneficiary Notice (ABN), you might not be responsible for paying these charges. You do not need an ABN if the services you require are not covered by Medicare. In this case, you are responsible for the entire cost of the visit. 

However, there are ways to protect yourself from Medicare Plan B Excess Charges. According to experts, you may want to only choose doctors who participate with Medicare Assignment. If you do this, you are not billed for services with a cost exceeding the amount Medicare will cover. You may want to ask your provider if they accept Medicare Assignment before you book an appointment with them.

You should also ask lab facilities and other medical service providers if they accept Medicare Advantage. If they do not, you may want to search for another doctor or lab facility. You can search online for professionals in your area who accept Medicare Assignment. If you want to avoid excess charges, you can purchase a Medigap plan that pays for these charges.

Of course, bear in mind that some states do not allow Medicare Part B Excess Charges to make life easier for seniors. Ohio, Minnesota, Rhode Island, and Vermont do not allow seniors to incur Medicare Part B Excess Charges. Pennsylvania, New York, and Massachusetts also do not allow Medicare Part B Excess Charges. This is a huge asset for seniors on a fixed income and for those who are at the poverty level. 

Individuals may benefit from getting a Medigap Plan with benefits similar to those of Plan G. Unfortunately, Plan N “does not cover” any excess charges you incur. 

However, if you live in a state without excess charges, you might benefit from Plan N. If you are out of your home state and require care, you need to ask providers if they accept Medicare Assignment. You are likely to see excess charges if you are treated for a medical emergency. However, there are a number of Medigap programs that cover these charges for you.

Let’s say you see a doctor you don’t normally see. If that doctor does not participate with Medicare Assignment, that doctor has the right to charge you $345, which is 15 percent above what you usually pay. Medicare Part B Excess Charges do not go toward your deductible, and you are responsible for paying 20 percent of the amount you typically pay for a service.

Medicare usually pays 80 percent of a bill, and you are responsible for the remaining 20 percent. What happens when your doctor accepts Medicare Assignment? Your doctor may charge $300 for a test that is done in the office. Your doctor will send the bill to Medicare, instead of requesting that you pay the bill upfront.

If the excess bill is for $300, you will only have to pay $60. Anything above that amount is covered by your insurance. Doctors who have not signed up with Medicare might still accept Medicare Assignment. However, they are not required to accept Medicare Assignment for each service they provide. These professionals are referred to as nonparticipating providers.

In some cases, doctors decide not to accept Medicare at all. When this is the case, these doctors will not be paid by Medicare. Doctors who accept Medicare have the ability to still sign a contract with Medicare. This allows them to accept Medicare Assignment on some occasions. 

However, these providers are not obligated to accept Medicare Assignment for all services they provide to a patient. What services are covered is up to the doctor or healthcare facility. What is covered is subject to change at every visit. This can be daunting for seniors who want to know what they should expect to pay for every medical visit. In 2016, Aetna said that nearly 100 percent of claims they received did not have excess charges. Patients cannot be charged any more than the 20 percent payment required by doctors and other medical professionals. 

A participating contract between doctors and their patients is typically good for one calendar year. However, a provider can switch from a participant to a nonparticipant at his or her discretion during any calendar year. Doctors benefit from being participants with Medicare. Providers who participate typically earn five percent more from Medicare than nonparticipants do. This should be an incentive for nonparticipating providers.

Additionally, those who participate have ready access to claim processing phone numbers. Physicians who call these numbers usually have their claims processed more quickly than they would if they were a nonparticipant. Doctors who participate with Medicare are often called PAR physicians. PAR physicians accept Medicare’s required amount as full payment for a visit or services. 

This policy applies to all patients who have Medicare. Although Medicare can impose an extra charge of 15 percent, that is the maximum. Excess charges will never exceed that amount. The Balanced Budget Act of 1997 gave Medicare patients and doctors the ability to privately contract with companies that are independent of Medicare.

This allows doctors to stop accepting Medicare, but this can cause problems if a doctor wants to switch back and accept Medicare again. If a doctor decides to accept Medicare again, he or she must wait two years until he or she can switch back. This is because you cannot submit claims to accept Medicare again for a period of two years. 

Because of this, it is wise for doctors to do their research before deciding not to accept Medicare. Excess charges are any charges that exceed Medicare’s maximum payout. Such charges are not only an inconvenience for many seniors. In some cases, these charges can cause financial distress, making it hard for many to pay for basic necessities.

A doctor has the right to impose excess charges on patients. Excess charges apply to a number of services, including home health care, testing services, and lab work.  

9 Sources

MedigapCoverage has strict sourcing guidelines to ensure our content is accurate and current. We rely on peer-reviewed studies, academic research institutions, and medical associations. We strive to use primary sources and refrain from using tertiary references.

https://boomerbenefits.com/part-b-excess-charges/

https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-b/index.html

https://www.aarp.org/health/medicare-qa-tool/define-term-medicare-assignment/

https://www.medicare.gov/care-compare/?redirect=true&providerType=Physician

https://www.aafp.org/family-physician/practice-and-career/getting-paid/medicare-options.html

https://www.congress.gov/bill/105th-congress/house-bill/2015

https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare

https://www.medicare.gov/basics/costs/medicare-costs/provider-accept-Medicare

https://www.medicare.gov/basics/your-medicare-rights/your-protections