Medicare Part B Excess

What is the Medicare Part B excess?

Medicare Part B excess only applies if you go to a physician or medical facility that does not accept Medicare assignment. Assignment means that the doctor, provider (medical facility), or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. Thus, if you are evaluated by a physician that does not accept Medicare assignment, then the physician is allowed to have an “excess charge.” The excess charge is amount the physician, supplier or medical facility charges that is above the amount Medicare has deemed reasonable and customary charges for a specific procedure or doctor office visit.

How much Part B excess do I have to pay?

If the amount Medicare has deemed reasonable and customary but the physician, supplier or medical facility does not agree with the amount then you can be billed for the difference. However, the Medicare beneficiary cannot be billed for more than 15% of the amount that Medicare has deemed reasonable and customary for the medical service.

Part B Excess Example:

If you are evaluated by a physician that does not accept Medicare assignment and charges $100.00 for his/her services but Medicare has deemed $60.00 is reasonable and customary, then Medicare will only pay the physician $60.00. Since the physician cannot bill you for more than 15% of the amount Medicare has deemed reasonable and customary, then you would be responsible for 15% of the $60.00 because this is amount Medicare has deemed reasonable and customary for the treatment at issue, not the $100.00 the doctor charges. The excess is calculated by multiplying the $60.00 by 15%. Therefore, 15% of $60.00 is equal to $9.00. The doctor will accept the $60.00 from Medicare, and may bill you for the excess of $9.00. This may not seem like a significant amount of money, but the excess charge can apply to medical facilities as well. If you were to undergo a procedure, such as an operation, at a medical facility that does not accept Medicare assignment and the overall bill is $10,000.00. If Medicare has deemed the reasonable amount for the operation is $7500.00, then you may be responsible for 15% of the $7500.00. Using the calculation method discussed above, the excess charge that could be billed to you is equal to $1125.00 (one thousand one hundred twenty-five dollars).

How do I avoid the Part B excess?

You can avoid the worry of Medicare Part B excess or paying the excess charge by purchasing a Medicare Supplement that covers the excess charge. Not all Medicare Supplements cover Part B excess charge. However, Medicare Supplement Plans F and G will cover the excess charge. Another way to avoid paying the excess charge is simply ask your physician, supplier or medical facility if they accept Medicare assignment. If the answer is yes, then you will not be responsible for any excess above what Medicare has deemed reasonable and customary for services provided.

Please note, however, that there are states that do not allow any excess charges to be billed to the Medicare beneficiary. These states include Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont. This is due to the MOM (Medicare Overage Measure) Law.

For more information on how to avoid the excess charge consult with a Medicare Pathways’ agent/benefit specialist by calling 1-866-466-9118 or by requesting a quote.

 

Medicare Pathways, Inc.

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