Social Security and Medicare Question

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Social Security and Medicare Question

Q: My Medicare HMO stopped service recently. Before my new Medigap policy became effective, an emergency forced me to go to a different doctor. I was asked to pay the office fees up-front and told to submit the bill to Medicare for reimbursement. The amount charged by the doctor was $250 but Medicare only reimbursed me for $76, because the doctor did not `accept assignment.` Doesn`t Medicare pay 80% after the $100 deductible? Shouldn`t I get reimbursed $120 (80% of the $150 balance)?

A: When doctors and suppliers agree to accept the Medicare approved amount for services as payment in full, they accept `assignment.` Medicare pays 80% of the Medicare approved amount and you pay 20%. If the doctor or supplier does not agree to accept assignment, you pay more.

There are limits to how much more you have to pay. If a doctor does not accept assignment he or she can legally charge 115% more than the Medicare approved amount. This is called the `limiting charge.` The problem is that most Medicare patients have no way of knowing what the limiting charge is at the time of receiving the service when you may be asked to pay the entire bill. Because doctors are required by law to submit all claims to Medicare, most will tell you the limiting charge and file the claim for you. But many do not.

Medicare patients have been charged millions of dollars over the legal limits. If you think you overpaid, check your Medicare Summary Notice (MSN), Medicare`s billing statement that you receive with your reimbursement. Find the NOTES section. It will tell you if a doctor has exceeded the limiting charge and the correct amount you owe under the law. With your MSN in hand, you may go back to your doctor`s office and ask for a refund. If you are not satisfied with the answer you receive or have questions about what doctors accept assignment, call the number of your Medicare `carrier` listed on your MSN.

How the System is Supposed to Work

Example: Mr. Jones` doctor does not accept assignment for service. Assume that Mr. Jones has paid his $100 Part B deductible for this year.

Amount charged by doctor	................ $150.00
Medicare approved amount of $100 is reduced by 5% for doctors who don`t accept assignment	................ $ 95.00
Amount doctor is legally allowed to charge Mr. Jones (115% more than $95). Mr. Jones submits the bill to Medicare	................ $109.25
Medicare pays Mr. Jones (80% of $95 Medicare-approved amount)	................ $ 76.00
Mr. Jones` portion of the bill the difference between what Medicare pays ($76) and the most the doctor can legally charge ($109.25)	................ $ 33.25

Amount overcharged by doctor if Mr. Jones paid $150 (difference between $150 and $109.25) refund due to Mr. Jones

................ $ 40.75

This article first appeared in Volume 6, Issue 4 of "The Social Security and Medicare Advisor" newsletter (March/2001). To receive future editions of "The Advisor" in its special, free e-mail version, please click here.