Medigap & Excess Part B Charges

[jvancleve]

You received a lot of information....some accurate and some not. Here is an excellent and accurate write up on how excess charges work if they are not banned by applicable state law.

Medicare Participation Options for Physicians -- Running a Practice -- AAFP

 

[Slade]

"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."

It can be confusing to see where the 9.25 comes from, so......

Where Y = Medicare Approved Amount

[(Y x .95) + (Y x .95 x .15)] - Y ÷ Y = .0925 or 9.25%

 

[yorkriver1]

Good source in the link, thanks, and the formula is appreciated. I get it now, after re-reading the link and the formula. Makes it one step in calculating the allowable total charge including excess, for non-par physicians. Also interesting, in giving the advice about what % of patients they would have to collect the 9.25% from to make up for the 5% lost off Medicare Allowable by being non-par.

 

[somarco]

From Jeff's link above, this should not be overlooked.

Those considering a change in status should first determine that they are not bound by any contractual arrangements with hospitals, health plans or other entities that require them to be PAR physicians.

If a doc has admitting privileges to a par hospital (which is virtually all hospitals) they are not allowed to opt out of Medicare assignment.

 

[yorkriver1]

I have an acquaintance who is a hospital pharmacist and also a patient in a concierge medical practice. I will ask how that works with this concierge doc, re: hospital admitting privileges.