Can a Provider Balance Bill Someone With Medicare?
Short answer
A provider who accepts Original Medicare assignment cannot bill above the Medicare-approved amount for a covered service other than applicable deductible and coinsurance. Certain nonparticipating providers may charge a limited excess amount when Medicare rules allow it.
Coverage
Assignment, nonparticipating-provider rules, limiting charges and private contracts determine what may be billed in Original Medicare.
Not Automatic
Noncovered services, opted-out private contracts and Medicare Advantage out-of-network billing are separate situations and should not be described as ordinary Part B excess charges.
Costs And Ma
Medicare Advantage members should use their plan’s network and billing protections rather than Original Medicare assignment rules.
Practical Example
A participating Original Medicare physician cannot add an extra ‘balance’ above the approved amount for the covered service simply because their usual fee is higher.
Questions to verify
- Did the provider accept assignment?
- Is this an Original Medicare or MA claim?
- Is any billed amount for a noncovered service or legal excess charge?