Medicare payment for participating , non participating physician

Medicare Part B Reimbursement of Physician Services

 The following examples show how basic reimbursement by Medicare Part B is calculated, depending on a physician ’ s participation status and whether or not assignment is accepted:

Participating Physician Must Always Accept Assignment

1. Submitted charge = $125.00
2. Medicare allowed (participating fee schedule) amount = $100.00
3. Medicare pays physician 80% = $80.00
4. Patient is billed for 20% coinsurance = $20.00

5. Physician may collect the 20% coinsurance amount from the patient = $20.00

Nonparticipating Physician Who Does Not Accept Assignment

1. Submitted charge (Medicare limiting charge) = $109.25
2. Medicare allowed (nonparticipating fee schedule) amount = $95.00
3. Medicare pays patient 80% of fee schedule = $76.00
4. Physician may collect from patient up to the limiting charge ($109.25) = $33.25

Note: This is the difference between the limiting charge ($109.25) and 80% of Medicare ’ s nonparticipating fee schedule allowed amount ($76.00).

Nonparticipating Physician Who Accepts Assignment

1. Submitted charge = $125.00
2. Medicare allowed (nonparticipating fee schedule) amount = $95.00
3. Medicare pays physician 80% of fee schedule = $76.00
4. Patient is billed for 20% coinsurance = $19.00
5. Physician may collect the 20% coinsurance amount from the patient = $19.00

Note : A physician may bill the beneficiary for all services that are excluded by Medicare, any unmet deductible, and the 20 percent coinsurance provided the claim is not subject to Medigap provisions for assigned claims.