Patient no Part B, question about provider billing

[yorkriver1]

If a patient has Part A but not Part B, is the physician doing a Part B procedure obligated to limit their charges to Medicare allowable rates? Assuming the physician accepts Medicare allowable charge. The patient would pay the whole allowable charge cost, not 20%, but that would be much lower than whatever a physician could charge someone not on Medicare.
In the process of thinking this through I found a tool on Medicare.gov I didn't know existed that gave the 2023 allowable charges for cataract surgery. [EXTERNAL LINK] - Procedure Price Lookup for Outpatient Services | Medicare.gov
Today I met with a referral, potential client couple, and one never enrolled in Part B, now needs cataract surgery and doesn't want to wait for Medicare Part B late enrollment starting in January.
They both only have Original Medicare so we will look at least at MAPD's for 2024, 2/1 for the spouse with no Part B now. They have financial means, so no mid year for extra help, etc.

 

[Fisher]

If a patient has Part A but not Part B, is the physician doing a Part B procedure obligated to limit their charges to Medicare allowable rates?

Interesting question and common sense would say the answer is no. The doctor will not be billing Medicare for the procedure so there are no constraints to the charges.

 

[yorkriver1]

Interesting question and common sense would say the answer is no. The doctor will not be billing Medicare for the procedure so there are no constraints to the charges.

That does make a kind of sense. The other consideration is whether the contract the providers make with Medicare when they agree to "accept allowable charges" would cross over to Part B even if the patient didn't have that coverage.
I am also thinking that with no coverage the patient can always negotiate about cost using the allowable charges as a talking point.

 

[somarco]

They can certainly ASK for a "discount" for the procedure but I don't see why the provider would be COMPELLED to reduce their fee to Medicare pricing levels.

 

[rmhaire]

They both only have Original Medicare so we will look at least at MAPD's for 2024, 2/1 for the spouse with no Part B now. They have financial means, so no mid year for extra help, etc.

Signing up for part B in January will trigger an automatic do-over for a supplement. No health questions.

 

[yorkriver1]

Signing up for part B in January will trigger an automatic do-over for a supplement. No health questions.

Thanks for the reminder, will present both options. 7 years into Medicare, the penalty may equal or exceed the cost of a supplement. I have 0 experience with someone getting the late Part B penalty, so not sure then they will be notified of the amount.

 

[yorkriver1]

They can certainly ASK for a "discount" for the procedure but I don't see why the provider would be COMPELLED to reduce their fee to Medicare pricing levels.

Yes, that may be their only option. My research on Medicare costs was essentially to give the future client a place to negotiate from if necessary. They could, if needing both eyes, maybe do one now and wait on the other until February. I see the charges show for one eye, so double for two.

 

[rmhaire]

Thanks for the reminder, will present both options. 7 years into Medicare, the penalty may equal or exceed the cost of a supplement. I have 0 experience with someone getting the late Part B penalty, so not sure then they will be notified of the amount.

I've had more than a few. The do-overs can come in handy. Especially if they have health problems. But I've never had one that was 7 years. That's a 70% penalty.

I have seen a couple where Medicare never got around to adding the penalty. And I'm talking 2 or 3 years back. I sure as hell ain't going to bring it up.

 

[yorkriver1]

I've had more than a few. The do-overs can come in handy. Especially if they have health problems. But I've never had one that was 7 years. That's a 70% penalty.

I have seen a couple where Medicare never got around to adding the penalty. And I'm talking 2 or 3 years back. I sure as hell ain't going to bring it up.

I won't mention that omission to the client, but good to know, what are the odds, probably not good.
Bonus info from call just ended with Social Security. 1. they have to apply in January (earliest of the 3 month window) with the same 40-B Part B app as anyone, but can't do it online, must go local. 2. the 10% for X # of years without Part B formula doesn't change but the calculated rate, for, say 7 or 8 years will be 10% of the Part B rate for each following calendar year. So roughly the price of a MedSupp for this situation, they can decide what they want for coverage.
Also called Medicare, was told the doc doesn't have to use Medicare allowable charges when the person doesn't have Part B. The rep also was not really familiar with the General Enrollment Period timing, told me I was confusing that with OEP for Medicare advantage, so I am mostly relying on the payment advice but info lacking about applying late for Part B. Sometimes we get a spot on person, sometimes not. Granted GEP is Social Security's area not Medicare.

 

[rmhaire]

but can't do it online, must go local. 2.

There's a form online that they can print out and mail it in. No need to walk in.