When you are covered by Medicare, it is important that you know whether or not your doctor accepts Medicare assignment. Assignment means that your doctor, provider or supplier agrees, or is required by law, to accept the Medicare approved amount as full payment for covered services. In most instances, providers and suppliers will accept Medicare assignment, however, it is always a good idea to ensure they do prior to moving forward with their services.
How does Medicare Assignment work?
For every procedure and service that is covered by Medicare, there is a Medicare approved price. Also known as Medicare Allowable Charges, the price is the total amount that Medicare will cover. Each doctor who accepts Medicare has the option to choose whether or not they want to accept Medicare’s allowable charges or not. Those that do accept Medicare “assignment.”
It’s the Doctor’s Choice
The first choice a doctor has is whether or not to accept Medicare. If they accept Medicare, they have to decide whether or not they will accept Medicare’s allowable charges as full payment. If they choose to accept Medicare’s price, that means they accept Medicare assignment. Accepting assignment also means that the provider will bill Medicare on your behalf. However, if they do not accept Medicare assignment, they are allowed to charge a patient up to 15% more than Medicare’s allowable charges. That 15% is called excess charge.
If you are wanting to avoid being charged an excess charge, you will want to make sure that you are seeing doctors who accepts Medicare assignment. When you are researching doctors you will want to keep in mind that just because they accept Medicare, it does not mean they accept Medicare assignment. Once you have verified that your provider accepts Medicare assignment, you will want to continue to check with them as you make subsequent appointments because doctors and suppliers can choose to no longer accept Medicare assignment at any time during the year.
The same goes for durable medical equipment (DME) suppliers, they also get to choose whether or not that want to accept Medicare assignment.
From The CMS Website: Here's what happens if your doctor, provider, or supplier doesn't accept Medicare assignment:
- You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
- They can't charge you for submitting a claim. If they don't submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.
- In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S to get paid back.
- They can charge you more than the Medicare-approved amount, but there's a limit called "the limiting charge ". The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.
The limiting charge applies only to certain Medicare-covered services and doesn't apply to some supplies and durable medical equipment.
State Specific Medicare Rules for Excess Charges:
There are a few states that prohibit excess charges and require the doctors to accept Medicare’s approved price for each service and procedure. Those states are:
- New York
- Rhode Island
Not sure if your doctor is covered by Medicare? Or accepts Medicare assignment? Give us a call and we can help you do the research.