Medigap & Excess Part B Charges

[billyg]

The issue we're seeing isn't doctors charging excess (not accepting assignment). The issue is with doctors not accepting new patients on Medicare or not accepting Medicare at all. This is becoming more challenging than ever.

There is way too much confusion about "excess" charges. Its understandable with the beneficiaries. It isn't so understandable with licensed agents.

 

[G.Gordon]

40%? Please provide proof that the physician can charge more than 15% of 95% of the allowable.

Rick

or... 9.25%.............

 

[GreenSky]

or... 9.25%.............

You and I know it's 9.25%. I didn't want to confuse him so I gave him the formula.

Rick

 

[DS4]

.. plus there is a limit of 40% cap on what the Dr can charge in excess.

OBRA 1990 capped non par Medicare providers as follows,
1991 125%
1992 120%
1993 115%

 

[G.Gordon]

I've had ONE client call back after that conversation. She said she called the prior agent, he told her I was a fool, that there is a limiting charge of 15%, but that 9.25% was something I made up.

I asked her, "If he knew of the limiting charge, why did he try to scare you into something else by telling you you'd be responsible for the entire balance?"

Then I explained the 15% after the Medicare approved rate was reduced 5% = 9.25%.

 

[coachd]

Way to many agents out there not really knowing what is going on. I fight it everyday. People scare a client. I always explain it. I was selling Plan G with the old plan. I have only seen 1 person have a doc charge this.

I never say it can not happen, but very few do.

 

[somarco]

Xs charges are more likely to occur with specialists and PARE claims where the dollar amount is significant.

 

[yorkriver1]

I've had ONE client call back after that conversation. She said she called the prior agent, he told her I was a fool, that there is a limiting charge of 15%, but that 9.25% was something I made up.

I asked her, "If he knew of the limiting charge, why did he try to scare you into something else by telling you you'd be responsible for the entire balance?"

Then I explained the 15% after the Medicare approved rate was reduced 5% = 9.25%.

You have a good handle on this. Can you tell me where to get more info? I did a search & read an AMA document for MD's online outlining Medicare participation rules, that mentioned the differences in reimbursement between those who "participate" (PAR) or those who don't (NONPAR). Is that reimbursement rule where your 5% discount number comes from?
Thanks!
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Way to many agents out there not really knowing what is going on. I fight it everyday. People scare a client. I always explain it. I was selling Plan G with the old plan. I have only seen 1 person have a doc charge this.

I never say it can not happen, but very few do.

I bow to the experiences of those who have been doing this a while. I do wonder about what may develop in future. Doc's may just go to concierge model instead of trying to get more by doing excess charges.

What about large B expenses like chemotherapy? No experiences of excess charges? What do the 20% amounts look like for those on plans, either Medigap or MAPD where they are essentially on the hook for the Part B 20% with a very large or no upside cap? I may post that as a separate thread, cancer experiences. I lucked out with a friend of mine turning 65, pretty healthy who insisted on buying a zero premium MAPD. Cancer was diagnosed 3 months in. His retired well to do friends told him to have him switch to Plan F on Trial Rights, stat. Whew! Suddenly $150/mo for Medigap + PDP was no problem. Love those friends who read "Choosing a Medigap Policy" page 23.....I had a bit of a time finding anyone in my upline sales organizations who was really familiar with Trial Rights...then in a miracle of RTM, or as some would say, RT*M, I found page 23..but I am not complaining, it seems that these things happen all 'round. Thanks!
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Xs charges are more likely to occur with specialists and PARE claims where the dollar amount is significant.

Yes, and being insurance people, we consider the outlier claims as well as the more frequent, or at least advise clients of the risks.
Sorry, I'm not familiar with the term PARE. I'm sure it'll be a forehead smacker. My hairline is getting a workout with that lately....
Thanks for your response.

 

[somarco]

PARE claims, AKA R A P E claims

Pathology
Anesthesiology
Radiology
Emergency


PARE claims from "hidden providers" occur with some frequency in the managed care (PPO, POS, etc) world of major med. I have no reason to believe it is much different with Medicare.

I do know a major bone of contention is medical transport where (so it seems) very few companies accept assignment. You also have a fair number (anecdotal) of ambulance claims that are denied by Medicare since they do not meet the definition of medically necessary. Of course in that case it doesn't matter if they accept assignment or not.

But big dollar PARE claims might just make it worth the providers time to avoid the haircut so they can bill XS charges.

 

[bill3173]

Xs charges are more likely to occur with specialists and PARE claims where the dollar amount is significant.

Excess charges are frequent in States where they are allowed. Can my clients find a specialist that accepts assignment? Hah, good luck.