Medigap & Excess Part B Charges
- Thread starter yorkriver1
- Start date
Yes, they are supposed to file the claim regardless, but the client has a right to self file in the event the provider does not do it in a timely manner.
Medicare will not pay after 15 months(unless something has changed), and I had a guy that was sitting on month 12 and filed it himself. The form is downloadable from the medicare site, I can think of it right now.
- 4,747
you are correct.............
Here's what happens if your doctor, provider, or supplier doesn't accept assignment:
You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
They can't charge you for submitting a claim. If they don't 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 paid back.
They can charge you more than the Medicare-approved amount, but there's 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.
Costs & assignment | Medicare.gov
You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
They can't charge you for submitting a claim. If they don't 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 paid back.
They can charge you more than the Medicare-approved amount, but there's 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.
Costs & assignment | Medicare.gov
- Thread starter
- #35
- 1,824
Thanks for answers, very helpful. Hope the doc's failure to file claim is rare event, but good to know what to do.
- 102
Guys, my mistake on the 40% I was trying to multitask and was reading five or six different things and I typed 40% by accident. Please for give me and the confusion with any one if I caused any. Again, sorry.
- 397
OK, I think its time to set the record straight. There appears to still be confusion about assignment and excess charges.
There are 3 possible ways a provider may relate to Medicare:
1. Not to participate in Medicare. This means they won't bill Medicare and in most cases they won't see any patients with Medicare as their primary insurance. The provider wants nothing to do with Medicare.
2. They don't accept assignment. This means they can still see Medicare patients, but the claim payments are not assigned to the provider, though the provider is still required to file the claim with Medicare. In this case the provider is allowed to charge excess charges of 15% (actually 9.25% as previously noted) above the Medicare allowed charge. The provider must collect the entire fee from the patient and Medicare sends the re-imbursement to the insured. This can (and frequently does) cause a collections problem for the provider since the provider must wait for the patient to pay the bill.
3. The provider accepts Medicare assignement (over 99% of all providers that participate in Medicare accept assignment). This means the provider files the claim with Medicare and recieves the assigned payment directly from Medicare.
Most of the confurion is coming from the situation where providers simply don't participate in Medicare. This situation is erroniously being reported as they "don't accept assignment", but in reality, they don't accept Medicare at all. In our area this is becoming the bigger problem.
There are 3 possible ways a provider may relate to Medicare:
1. Not to participate in Medicare. This means they won't bill Medicare and in most cases they won't see any patients with Medicare as their primary insurance. The provider wants nothing to do with Medicare.
2. They don't accept assignment. This means they can still see Medicare patients, but the claim payments are not assigned to the provider, though the provider is still required to file the claim with Medicare. In this case the provider is allowed to charge excess charges of 15% (actually 9.25% as previously noted) above the Medicare allowed charge. The provider must collect the entire fee from the patient and Medicare sends the re-imbursement to the insured. This can (and frequently does) cause a collections problem for the provider since the provider must wait for the patient to pay the bill.
3. The provider accepts Medicare assignement (over 99% of all providers that participate in Medicare accept assignment). This means the provider files the claim with Medicare and recieves the assigned payment directly from Medicare.
Most of the confurion is coming from the situation where providers simply don't participate in Medicare. This situation is erroniously being reported as they "don't accept assignment", but in reality, they don't accept Medicare at all. In our area this is becoming the bigger problem.
Last edited:
- 700
I ve got to think that if they quit passing the doc fix program, you ll see way more charge them in the future. In 15yrs in the business, i rarely run into it now...
- Thread starter
- #40
- 1,824
Thanks, this tracks what I found looking up these terms on Medicare.gov. My head hasn't quite got around the math about "non-Par" doc's billing Medicare and getting 95% of allowable, then billing excess charges of whatever, then it's 9.5%, etc, but I will get it on further review.
I have 2 friends who have gone the "concierge" or, as the official term is stated: "private contracting physician" route with a doc who doesn't take insurance *or* Medicare. My friends pay about $1,500 a year for each family member if I recall, and have comparatively lavish options for time with the doc. Other physicians who "opt out", another term from CMS, aren't necessarily concierge, but just demand payment direct from the patient. Most importantly, Medicare doesn't pay for any charges for "opt out" doc's, just for doc's who are "Par" and "Non-Par".
I am finding for lots of questions about Medicare that reading more of even the simple "Medicare and You" book is helpful (RTM). Just looking on Medicare.gov is good, too.
Any other suggestions are welcome.
Last edited:
