What is a Medicare Part B Excess Charge?

by Mary Jane Stern

Many people struggle trying to understand what a Medicare Part B Excess charge is.  I know I did initially. It’s an additional charge a physician or other healthcare provider can charge.

There are many doctors and facilities who accept the Medicare allowed charge.  However, there are also doctors and other healthcare providers who DO NOT accept the allowed charge and have excess or additional charges.

Here’s an Example of a Medicare Excess Charge

Jane is visiting a new physician for an office visit and has Original Medicare Part A and Part B, but no supplemental insurance.  Medicare’s allowed charge for her visit is $100.  The physician has the option and a right to charge up to 15% over the Medicare approved charge.

Jane’s physician doesn’t accept the Medicare allowed payment and charges the additional 15 percent or in this case $15.00.

The allowed charge is $100 and Medicare will pay 80%, which means they will send the physician $80.00.  You are responsible for the 20% or $20 plus the 15% Medicare excess charges or $15.00 making your out-of- pocket cost $35.

Remember, if a doctor or other healthcare provider does not accept Medicare assignment, (Medicare refers to them as a nonparticipating provider), they can charge you, the patient, for the co-insurance plus an additional 15% of the total allowed charge.

Do You Have Supplemental Insurance?

In the above example Jane doesn’t have any supplemental (Medigap) coverage.  She is 100% responsible for the 20% ($20) and the 15% ($15) excess charge.

There are Medigap plans that DO cover the excess charge and most do.  If you are not enrolled in a Medicare Advantage Plan, and have Original Medicare A and B, you should consider a Medigap plan.  It will help, especially if you have any type of chronic illness.

The good news is that right now there are only a few healthcare providers that actually charge more than the Medicare payment.

It would be a great resource to list here any physicians or other healthcare providers who do not accept the Medicare allowed charge and charge the 15% excess. If you know of any, let us know and we will start keeping a list.