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Excess Charges

Medicare Made Easy

Excess Charges

Medicare Part B “Excess Charges” is a term that you might have heard in relation to Medicare Supplement, or Medigap, plans.

Medicare Excess Charges are charges that a doctor adds above and beyond the Medicare-approved amount for a procedure or service

Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

If your doctor, provider, or supplier accepts assignment, your out-of-pocket costs may be less, they agree to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share, and they have to submit your claim directly to Medicare and cannot charge you for submitting the claim.

If your doctor, provider, or supplier does not accept assignment they are “Non-participating” providers and have not signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services.

If your doctor, provider, or supplier does not accept assignment, you may have to pay the entire charge at the time of service. They can also charge you more than the Medicare-approved amount, called “Excess Charges.” Excess Charges have a limit called “the limiting charge.” The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount. The limiting charge applies only to certain Medicare-covered services and doesn’t apply to some supplies and durable medical equipment.

It is up to the Medicare recipient to ask that provider the assignment question. It’s really quite easy, just ask the person in his or her office that handles billing/insurance.

If they see Medicare patients, they will know if they accept the Medicare-approved amount. Now of course if you have a stroke or get hit by a car it’s not even possible to ask that question and that’s why it is very important to have a Medigap plan to cover that benefit.

There are some Medigap plans that will protect you from paying excess charges, and then some Medigap plans that won’t.

Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you. They cannot charge you for submitting a claim. If they do not submit the Medicare claim once you ask them to, call 1 800 MEDICARE.

In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S to get reimbursed.

Find out if your doctors and other health care providers accept assignment or participate in Medicare.

Next, learn: Medicare Extra Help

Need help? Call us for an appointment at (817) 952-3153

Ashford Insurance is an independent health insurance agency specializing in Texas & Oklahoma Medicare insurance. Ashford Insurance is here to help you understand Medicare in simple, plain terms that anyone can understand.  We specialize in helping folks who are Medicare eligible to learn about the coverage options available through the Medicare Health Insurance Program. 

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