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Newsletter Archives > Unassigned Claims Continued


19 Nov 2007

Unassigned Claims Continued
For Agents Information Only

I got some questions and comments about my last email " Unassigned Claims, Excess Charges etc."

They were very good so I wanted to share:

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Q: "Doesn't NY limit excess charges doctors can charge to 105% of Medicare approved charges???
Otherwise a Dr could charge whatever and the med sup would have to pay it. "

A: You are correct......there are a couple exceptions like durable medical equipment etc. (actually there are a few exceptions--I am waiting to hear back on them).

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Q: Are there doctors that don't accept medicare?  If a doctor does not accept assignment does that mean he does not accept medicare?  Would your explanation apply to the following example... Patient sees a specialist in Manhattan that does not accept medicare or assignment [if they are the same], the doctor bills patient $1,000.  Patient submits bill to medicare and medicare approves $700 and pays 80% or $560.  Will plan F pay the difference of $440?

A: There are MD's who will not deal with Medicare at all but they must tell the patient in writing up front - if that's the case then Medicare wont pay and a supplement wont pay either.  Not accepting assignment just means the MD will not accept Medicare's "approved amount" they want to collect the total amount they bill.  In NY MD's are limited (limiting charge law) to 105% of Medicare's approved amount.....in other words they can only charge 5% more then what Medicare approves.  I'm putting together an excel spread sheet to show you how it works.
 
See attached Spread Sheet - let me know if it makes sense.  In your example of $1000 billed and $700 approved you should be aware of the limiting charge law which in this case would only allow the MD to charge $35 more then what Medicare Approved - $700 X 105% = $35.00 *

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* Note:  The limiting charge in NY is 5%.  In other words MD's can only charge 5% more then what Medicare Approves.  Plan-F would pay, 1: The Part-B Deductible if applicable 2) the 20% of the approved amount 3) 100% of the legal excess charge.  Outside NY the limiting charge is 15% and Plan-F would pay it because it is a legal charge.

Todd Concklin