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Original Fee-For-Service Medicare: How To Maximize Use

Elective Surgery That Costs $500 Or More By A Non-Participating Doctor

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Medicare Part B requires non-participating physicians to provide written notice to Medicare patients before performing, and billing for, any elective (non-emergency) and non-assigned surgical procedure with total charges estimated at $500 or more. At a minimum, this notification must include:

  • The physician's estimated actual charge for the procedure. The actual billed or collected charge may not be greater than Medicare's limiting charge amount for the procedure. You are not liable for, and are entitled to a refund of, any amount billed or collected above the limiting charge.
  • The estimated Medicare approved charges.
  • The excess of the physician's actual charge over the approved charge.
  • The applicable coinsurance amount.

This written notice requirement applies to services furnished by non-participating physicians and assistant surgeons and anesthesia services personally provided by a non-participating surgeon or assistant surgeon. They do not apply to services furnished by non-participating anesthesiologists.

If you are using a non-participating doctor and you do not receive written notice prior to receiving the services, you are entitled to a refund of any money collected in excess of the Medicare payment. If the money is not refunded, the physician may be subject to civil money penalties and/or exclusion from the Medicare program.

Following is a sample notice that you may receive from a physician if the charge is over $500:

 

 

Date: ________________

 

Dear _________________:
(Beneficiary Name)

I am not accepting assignment for your elective surgery. The law requires me to provide the following information to you prior to any elective surgery where assignment is not taken and the charge is $500 or more. These estimates assume that you have met the $100 annual Part B Medicare deductible.

 

Type of surgery:

____________________________________

Estimated charge: 

$____________

Medicare estimated payment:

$____________

Your estimated payment: 

$____________ (Includes your Medicare coinsurance)

 

Sincerely,

_____________________________

(Physician Name and Signature)

 

Acknowledged and Agreed by: ___________________________
(Beneficiary/Legal Representative Name and Signature)

Date: ____________________

 

 

Private Contract Physician

 A doctor may "opt out of Medicare" and get around the Medicare billing limits by asking you to sign a "Private Contract." A Private Contract indicates the doctor's intent not to provide services through Medicare and to bill you for the entire charge.

A Private Contract Physician must present you with a written agreement that you sign before any services are provided to help Medicare recipients avoid being treated by such a physician mistakenly. You cannot be asked to sign a Private Contract when you are facing an emergency or urgent health situation.  

Providers who ask for Private Contracts are prohibited from billing Medicare for services or supplies for any Medicare beneficiary for at least two years.

 Under a Private Contract:

  • No payment will be made from Medicare at all will be made for the services you receive.
  • You will have to pay whatever the doctor charges you with no limit on the amount of the charges.
  • Most Medigap policies and many other health insurance plans will not pay anything towards these charges as well. 

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