Most patients won’t have any issues with Medicare Part B excess charges. However, that does not mean you shouldn’t be prepared if this situation comes up. An excess charge happens when you visit a doctor that does not accept Medicare as a full payment for certain healthcare services. If this happens, the doctor has the option to charge you up to 15% more for that service than the Medicare-approved amount. This article will walk you through how excess charges function and what you can do to ensure you’re never hit with one.
What Does Medicare Part B Cover?
Before rushing into Medicare Part B excess charges, we’ll quickly go over what Medicare Part B is. Part B is the part of Medicare that will cover your outpatient services. Examples of outpatient services are doctor’s visits and preventative care.
Some of the services covered by Part B are:
- flu shot
- cancer and diabetes screenings
- emergency room services
- mental health care
- ambulance services
- laboratory testing
What is a Medicare Part B Excess Charges?
Most healthcare providers will accept Medicare assignment. In other words, these providers have agreed with Medicare’s payments rates and terms and will bill Medicare accordingly.
However, some doctors out there have chosen not to accept Medicare assignment and can therefore charge you up to 15% more than the Medicare-approved amount for certain services. You may also hear this practice called balance-billing.
There are currently some 96% of doctor’s offices nationwide participating in the Medicare program, and these offices will only charge the Medicare-approved amount for covered services.
How Do Medicare Part B Excess Charges Work?
We’ll give you an example:
Say you go to visit a nonparticipating orthopedic specialist because you’re experiencing a pain in your arm. The doctor gives a diagnosis, and the Medicare-allowable charge for the service is $400. The office would be allowed to charge you an extra $60 for your care since $60 is 15% of $400. If you have already met your Part B deductible for the year, your out-of-pocket costs for this doctor’s visit would be $60, plus the 20% coinsurance charge. The 20% coinsurance charge on a $400 treatment would be $80. In total, you would be on the hook for $140 out-of-pocket.
How to Avoid Part B Excess Charges
The most simple way of avoiding excess charges is to not go to doctor’s that don’t accept Medicare assignment. This is pretty easy to do. All you have to do is ask the doctor’s office if they accept assignment when you’re trying to schedule an appointment.
Another way to find out if your doctor accepts Medicare is to use the medicare.gov physician finder tool. This cool tool helps to find doctors in your area that participate in Medicare, plus it can save you the hassle of a phone call and asking questions.
Your third option would be to supplement your Medicare coverage with a Medicare Supplement plan, also called a Medigap plan. Depending on which Medigap plan you choose, you could have all excess charges covered.
Medicare Overcharge Measure
Depending on where you live, you may never have to worry about Medicare Part B excess charges at all. That is because some states have made it illegal to charge excess rates, using what’s called The Medicare Overcharge Measure. There are currently eight states participating in the Overcharge Measure, and the eight states are:
- Connecticut
- Massachusetts
- Minnesota
- New York
- Ohio
- Pennsylvania
- Rhode Island
- Vermont
Medigap Plans and Part B Excess Charges
There are currently 12 Medigap plans on the market, though only 10 are available to new enrollees. These plans have varying degrees of coverage, but all of them aim to fill in at least some of the gaps that Original Medicare leaves behind. Each person is different, and the different plans have different costs, but it may be worth looking into a high-coverage Medigap plan if you are unhealthy and often visit the doctor’s office.
For the most coverage, you’ll want to get one of two Medigap plans:
Medigap Plan F
Unfortunately, Plan F is no longer available to new enrollees because the government phased out Plan F in 2020. However, if you currently have Plan F, you can keep it. Under Plan F, you are protected from Part B excess charges, meaning you can visit any doctor you would like for Medicare-covered services.
Medigap Plan G
Plan G is quickly becoming one of the most popular plans on the market now that Plan F has been phased out. Plan G is nearly as comprehensive as Plan F, except you have to pay for your Medicare Part B deductible under Plan G. Once you have paid the deductible – which is $203 in 2021 – Plan G will cover all of your remaining Part B costs. And, like Plan F, Plan G protects you from any Part B excess charges.
One last thing to note about Medigap plans is that their care is standardized across the U.S. This means that you receive the same care with your letter plan no matter who you are or where you live. The costs of the plan will differ depending on your personal health situation as well as your location, but the benefits of the plan are the same everywhere.
Should I Ask Every Provider About Excess Fees?
It’s probably a good idea to ask about excess charges every time you book an appointment with a new healthcare provider. The office will tell you upfront whether or not they accept Medicare assignment, and if they do not accept it, you can search for a new doctor if you’d like. It’s better to ask upfront and potentially have an awkward conversation than to receive a surprise bill in the mail.
Medicare Excess Charges
While it’s highly unlikely that you’ll get dinged with an excess charge since 96% of doctor’s in America accept Medicare assignment, it’s always good to know this information. In addition to asking providers if they accept Medicare, you can cover yourself further by enrolling in a comprehensive Medigap plan. To learn more about your Medigap options, call or email us today to get in contact with one of our licensed agents.
