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has anyone here had a client run into trouble with this?
C & D dont cover this..any thoughts on this are appreciated
Joe
C & D dont cover this..any thoughts on this are appreciated
Joe
Part B Excess Charges
- Thread starter pahealthquotes
- Start date
I had a client that I wrote back in 2003 on a plan that didn't pay excess charges. She went to the Mayo Clinic in Jacksonville,FL. and had to pay the unapproved/excess charges because they don't accept Medicare assignment.
I always write plan F now, if possible.
I always write plan F now, if possible.
- 7,790
In PA, tio the best of my knowledge, doctors are prohibited from balance billing (excess charges).
Now I understand your stamina for F/G plans. I've had clients go to Mayo. Mayo does not accept medicare, but will file the claim. For the clients I've had the used Mayo and were on C, D, E, etc. plans the difference between what they would have had to pay on those plans vs G, F, J, etc is very little. In very little I mean less than $100-200 compared to the overall balance due to Mayo. Mayo does not adjust their rates one bit no matter what the source of payment. Your client was told this as were mine. Actually they have to sign something saying they understand... per CMS rights/protections.
In the other thread we've had this discussion... even if that client said they were Mayo bound and the difference in premiums were what I quoted... I'd still write the D in a heart beat. Of course I'd explain that they will have a few bucks more out of pocket, but they are going to pay a bit anyway no matter what plan they are on.
Going to Mayo on F/G does not mean you'll have a $0 balance when all the insurances pay. F/G will only pay 13.5% over what the medicare approved amounts were for those services the bene received at Mayo... not the total gap in the amounts.
Been there... done that.
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It's not just PA, but a CMS protection. Anyone seeing a medicare provider that accepts assignment is protected from balance billing. Now a bene can see a provider that will file the claim, but does not accept assignment and they must notify the bene before services are provided. With this type of provider the form signed by the bene allows the provider to bill for the balance.
Then there are those providers that don't accept medicare at all, but will see beneficiaries that sign a financial obligation contract. They won't even help file the claim and medicare won't pay if it gets filed.
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It was for surgical charges....several hundred dollars....Medicare Coverage and Claims Information, Mayo Clinic in Jacksonville, Fla.
- 7,790
G.Gordon, I beg to differ with you. It is a state by state rregulation---not a CMS regulation. Doctors who accept Medicare may charge up to 115% of what Medicare pays; however, in PA they are not permitted to do so.
I'm going to call MoO tomorrow and ask them what they mean in their outline-of-coverage when it states under plan F...Part B Excess Charges(above Medicare Approved Amounts)...plan F pays....100% of the excess charges...insured pays $0.
If there is a balance above that, that is misleading. I've always been under the impression that a zero balance is a zero balance.
If there is a balance above that, that is misleading. I've always been under the impression that a zero balance is a zero balance.
- 7,790
Russ, CMS allows doctors who accept Medicare to charge 115% instead of just 100% of what Mediacre pays. In other words, if Medicare pays $100 for a specific charge, then a doctor may charge up to $115---but not more than 15% above the Medicare charge. In your example, Plan F would pay the Medicare approved charge PLUS the additional 15% above that charge. However, to reiterate, in PA that excess charge (or balance billing) is not permitted so that feature of Plan F is superfluous in PA.
