What are Part B excess medical expenses on a Medicare Supplement?


Before I get started writing this article, let me say this.  This subject is one of the most confusing benefits of a Medicare Supplement.   In this article, I hope to be able to explain the part b excess benefit so it is easy to understand part b excess medical expenses.  My name is Mitch Winstead with Allstar Senior benefits.  Call us today for a quote on a Medicare Supplement of any health or life insurance policy.  Our toll-free number is 866-598-8170.  910-538-4547.  Our website is www.allstarseniorbenefits.com.  Our email address is mitch@allstarseniorbenefits.com.  Our Facebook page is www.facebook.com/medsuppguru.    Here is some background information on our agency. I have been working in the physical therapy field for  24 years. Through that, I have helped thousands of patients recover from strokes, Parkinson’s disease, cardiac problems, total hip and total knee replacements just to name a few.   There a NOT a whole of agents that can say that. I co-own a physical therapy practice called physical therapy for life.  I got started in the insurance profession 18 years.  Our agency has been helping people for 34 years.  We know Medicare and have more knowledge than 97% of the agents today   Why?  I have worked as a healthcare provider for 24 years and Medicare is billed for my services.  This agency is veteran owned. I know things that other agents do not know for example, what codes are used in the billing process.   What do the letter codes mean on a Medicare explanation of benefits that patients/clients receive after a service? We know how the Medicare billing system works.  We have an extensive knowledge of medications that agents have to know in order to place you with the right company.  We know them-most agents don’t.  How are claims actually paid and what is the process.  We know underwriting ( health questions on the application to qualify) and how that work to place you with the right company that best for you.   I still help a few people rehab every week for various conditions.  We know Medicare!!  We know Medicare Supplements !!  There are a lot of agents claiming they are the best but when you put them on the spot-they can’t answer questions that impact you.  They are not able to help you effectively. My advice is to hire an experienced brokerage like Allstar Senior Benefits that can impart their knowledge to you and help you better.   Now back to the subject of Medicare Supplements.    When you look at the plans that are available on a Medicare Supplement, you will see that Plan F and Plan G have the part b excess benefit available.   For most people, this benefit is rarely used.  In all the years that I have been selling Medicare Supplements, part b excess charges do not inhibit anyone from purchasing a policy.  Here is why- 95% of providers in an outpatient setting take Medicare.  When I say providers, that means, chiropractors, physical therapists, x-ray facilities, and surgical centers etc.   These services fall under the category of outpatient services these days. Let’s take a look at the definition of what Medicare assignment is.  Hopefully, this article will help answer how common are Medicare excess charges?   Moreover, what is an excess charge?

Part B excess explained

This is straight from the Medicare Guide that most everyone gets each year.  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. It goes on to say make sure your doctor, provider, or supplier accepts assignment.  However, you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services. Here is what happens if your doctor, provider, or supplier accepts assignment:

Your out-of-pocket cost may be less than they agreed to charge you only the Medicare deductible and coinsurance amount.  They usually wait for Medicare to pay your bill before asking you to pay your share.  They have to submit your claim directly to Medicare and can’t charge you for submitting the claim.   Now let’s take a look at what happens if a Medicare provider does not accept assignment.  

 Non-participating providers that haven’t signed an agreement accept assignment for all Medicare-covered services.  These providers are called non-participating.   In this case, you might have to pay the entire charge at the time of services. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide for you.  They can’t charge you for submitting a claim.  If they don’t submit the Medicare claim once you ask them to,  you are supposed 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.  Because they are a non-participating provider, they can charge you more than the Medicare-approved amount but there is a limit called the ( limiting charge). The provider can only charge you 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 does not apply to some supplies and durable medical equipment. It is best to call the provider that is providing the outpatient services and ask him or her if they accept Medicare assignment. When you visit an outpatient provider, that office agrees with Medicare as far as accepting what Medicare allows for their services. For example, you go see Dr. Smith for a visit.  Dr. Smith charges you $100.00 for a service he provides, he has to accept what Medicare says they will pay him for services.   Now let’s take that example and add a little twist to it.   If  Dr. Smith is a non-participating provider which means does not accept Medicare assignment, he does not accept what the Medicare reimbursement fee for his for the services he provided you.   Since Dr. Smith is a non-participating provider your bill is now $115.00.   He can now charge you 15% more in this scenario.  The part b excess benefit on a Plan F and G will pay the 15% excess.   It is a little complicated to understand.  Please call me for any questions you have.


Grey Areas

Now let’s take a look at another situation that happens with Medicare and a Medicare supplement. I would say a majority of doctors providers or suppliers take Medicare. However, you will find that not every doctor will take Medicare. So I would suggest in that case is to find another doctor that does take Medicare. Sometimes that is just reality of what happens in a doctor’s  or providers practice.  I have found out during the course of the years that some eye doctors, dermatologists, and chiropractors, do not accept Medicare.  Here is another thing that can occur.  Some doctors take  Medicare but they are not accepting new Medicare patients. In that scenario, you would have to find another doctor that does accept Medicare. I think that is just a reality of the day and time or in nowadays where doctors and providers can exert their choice in whether to take Medicare patients or not.


Another thing that I want to explain is something my mother taught me many years ago.  When you have a Medicare Supplement policy, and you are confronted by the receptionist or person doing the billing in a doctor’s office when you check out.

I’ve heard this story many times from my clients. Here is the scenario.    You have Medicare and you have a Medicare Supplement. you go out to the window at the doctor’s office and you are checking out to make another appointment and the receptionist or billing person says Mrs.Jones we need to take a $15- $25 copay for today’s visit with the doctor.  Mrs. Jones who has a plan F,  Plan D,  Plan G or a plan C, is most likely wondering- why is my doctor asking me to give them a $15- $25 copay when I pay for a Medicare Supplement insurance each month.  They ask themselves shouldn’t it be covered and I should not have to pay a co-pay.   Here is what happens. Sometimes the doctor or provider once to bill you up front and charge you a co-pay.    The lady or gentleman at the checkout desk say to you after you question them why am I paying a co-pay? Well, we will reimburse you once we get our payment from Medicare.    Here’s where it gets into a little bit of a gray area. First of all the doctor or provider should not be asking a copay from you.   The reason why is because if you have a Medicare Supplement Plan F, Plan D, Plan C or Plan G there is no co-payment required. So the doctor wants their money up front and has the patient pay a co-pay and I hope they are being honest and will give the patient their money back.  From what my clients tell me this happens a lot. I’m not picking on any doctors or chiropractors in particular.  These are some stories I hear from my clients. One of the reasons you should not pay a co-pay is that Medicare is going to reimburse the doctor provider or supplier. The bottom line is that in two weeks usually, the doctor, provider, and supplier will receive payment from Medicare for the service they provide for you.  On some occasions, the Medicare reimbursement may not happen in two weeks.  If there is a coding error in the doctor’s suppliers providers billing system. In that case, the code has to be corrected and resubmitted to Medicare, and then they will still get reimbursed for the service they provide you.  Anyway, you slice it that is not your problem.  Sometimes this happens because the doctor, provider or suppliers don’t want to wait for Medicare to pay them.  So if they can get the money up front from you they don’t have to go through a bunch of hoops and red tape to get their money in two weeks from Medicare. I hope what I’m going to say next doesn’t happen. I hope that if a patient pays for a copay or a doctor’s visit, that the provider doctor, supplier, or provider will reimburse the patient. So let’s go back again to what my mother taught me many years ago.  I actually explain to clients not to pay their co-pay or their service up front if they have a Medicare Supplement Plan F, G, C or D. I say to them the receptionist or billing person may give you a dirty look because they were trained by a provider doctor supplier to ask for the money up front.  When you don’t cooperate they start getting upset.

What is the best thing to do?

My mother and I explain to our clients when asked for a co-pay or for the cost of the visit, is to tell the receptionist or billing person that you don’t have any cash on you.   You don’t have a credit or debit card or checkbook. The doctor, supplier or provider is still going to get their money for the service they provided you. It is just not going to be immediate.  They have to wait approximately two weeks to get their reimbursement from Medicare.

Here is another thing that happens sometimes in a doctor, provider or suppliers office. Sometimes not all services or treatments are covered by Medicare.  I explain to my clients that if you go for a visit to your doctor’s office and receive treatment is to make sure you ask the doctor supplier provider this question. Is my service or treatment you’re providing me today covered by Medicare? Here’s what happened to one of my clients in South Carolina. She went to see a doctor that was about a hundred miles away from her home. The doctor gave her an experimental treatment at her doctor’s visit. So about 20 days later she receives a bill from the doctor and then calls me. She asks why am I getting a bill from this doctor when I have a Medicare Supplement Plan F. So what I usually do in that scenario is have the client make a copy of the bill. I then make a couple phone calls to the Medicare supplement company regarding the service and claim on that date. I then call the doctor’s office and ask them if they submitted a claim and then also was it a Medicare-approved item or service.   In this case, I explain to my clients that if you go to a doctor, provider or supplier and they have a treatment they’re going to give you.   You need to ask the doctor or nurse the following question.  Is my Medicare going to cover this? if the doctor’s office or supplier provider cannot answer that question. Then you need to tell them I don’t want to receive a bill for this.  Let me be clear, 95 percent of the services at a doctor’s office is covered by Medicare.  I need to explain this. if Medicare does not cover your service or item or supply, then the Medicare supplement will not cover it either.  We offer free advice with no obligations.  If you have any questions about this article. or if you want a quote on Medicare supplement insurance. Or any other type of insurance, please call our office toll free at 866-598-8170. or 910-538-4547.  All of our policies and plans are state approved and state regulated. If you would like a quote, please click this link https://allstarseniorbenefits.com/get-a-quote/#.W60lbGhKhPY  and complete the quote form. Our website is at his link https://www.allstarseniorbenefits.com. Our email address is mitch@allstarseniorbenefits.com Our Facebook page is at this link http://www.facebook.com/medsuppguru.  This article was written by Mitch Winstead.  Thanks for reading!