Part B Excess Charges: What They Are

Part B excess charges are extra fees that some doctors charge on top of what Medicare pays them. When a doctor does not accept Medicare's approved amount as full payment, they can bill you for the difference — and that difference is the excess charge.

Here is how it works: Medicare sets an approved amount for each service. Your doctor gets paid that amount. If your doctor is not a Medicare participating provider, they can charge you up to 15% more than Medicare's approved amount. That extra 15% is the excess charge, and you are responsible for paying it out of your own pocket.

Not all doctors charge excess fees. Doctors who are participating providers agree to accept Medicare's approved amount as full payment and cannot charge you more. Doctors who are non-participating providers can charge excess fees, but they do not have to — some choose not to.

Key Takeaways

  • Excess charges are fees above Medicare's approved amount that non-participating doctors can add to your bill, up to 15% more.
  • You pay excess charges directly to the doctor; Medicare does not cover them and they do not count toward your Part B deductible or out-of-pocket maximum.
  • Participating providers cannot charge excess fees because they agree to accept Medicare's approved amount as full payment.
  • Before scheduling with a non-participating doctor, ask whether they charge excess fees and request an estimate in writing.
  • You can check a doctor's participation status on Medicare.gov or by calling 1-800-MEDICARE.

How Excess Charges Differ From Your Regular Part B Costs

When you see a participating provider, your costs are straightforward: Medicare pays its share, you pay your coinsurance (usually 20% of the approved amount), and that is the end of it. Excess charges do not exist in that scenario.

With a non-participating provider who charges excess fees, the math changes. Let us say Medicare's approved amount for a service is $100. The doctor charges $115 (15% excess). Medicare pays $80 (its 80% share of the approved amount). You owe $20 in coinsurance plus $15 in excess charges — a total of $35 instead of the $20 you would pay at a participating provider.

Excess charges also do not count toward your Part B deductible or your out-of-pocket spending limit. This means they can add up quickly without any cap on your total costs for the year.

Finding Out If Your Doctor Charges Excess Fees

The best time to find out is before you schedule an appointment. Call the doctor's office directly and ask: "Does this doctor accept Medicare assignment?" or "Does this doctor charge excess fees above Medicare's approved amount?" Write down the answer and ask for it in writing if possible.

You can also check on Medicare.gov. Go to the "Care Providers" section and search for the doctor by name and location. The search results will show whether the doctor is a participating provider or non-participating provider. If they are non-participating, the listing will note that they may charge excess fees.

Another option is to call 1-800-MEDICARE and give them the doctor's name. A representative can tell you the doctor's participation status and whether they have a history of charging excess fees.

What to Do If You Receive an Excess Charge Bill

If you receive a bill that includes an excess charge, first verify that the doctor is actually non-participating. Check Medicare.gov or call 1-800-MEDICARE to confirm. If the doctor is participating and charged you an excess fee, that is a billing error and you should not pay it.

If the doctor is non-participating and the excess charge is legitimate, you have the right to dispute it if you believe it is unreasonable. Contact your Medicare Administrative Contractor (MAC) — the organization that processes Medicare claims in your region. Your MAC can review whether the charge follows Medicare rules. You can find your MAC's contact information on Medicare.gov.

Keep all bills and documentation. If you paid an excess charge and later discover the doctor should have been participating, you may be able to recover that money by filing a complaint with your state's medical board or your state's insurance commissioner.

Protecting Yourself From Unexpected Excess Charges

Before any procedure or visit with a non-participating provider, ask for an estimate in writing that breaks down the Medicare-approved amount, the excess charge, and your total out-of-pocket cost. This gives you a clear picture before you commit.

If you have a Medigap or Medicare Advantage plan, check your plan documents to see whether excess charges are covered. Some Medigap plans cover excess charges; most Medicare Advantage plans do not because they typically work only with participating providers.

When you have a choice between a participating and non-participating provider, choosing the participating provider eliminates excess charges entirely. If you must see a non-participating provider, ask them to accept Medicare assignment for your visit — some will do this even if they do not participate overall.

Excess Charges and Medicare Advantage Plans

If you are enrolled in a Medicare Advantage plan, excess charges work differently. Most Medicare Advantage plans contract only with participating providers in their network. If you see an in-network provider, that provider cannot charge excess fees because they have agreed to the plan's payment terms.

If you see an out-of-network provider with a Medicare Advantage plan, you may face excess charges, and your plan may not cover them at all. This is one reason why staying in-network with Medicare Advantage is important for controlling your costs.

Frequently Asked Questions

Can a doctor charge me an excess fee if I have not met my Part B deductible?

Yes. Excess charges are separate from your deductible and coinsurance. You owe the excess charge regardless of whether you have met your deductible. The excess charge does not count toward your deductible either.

What is the maximum excess charge a doctor can bill?

Non-participating doctors can charge up to 15% above Medicare's approved amount. That 15% is the legal limit. If a doctor charges more than 15%, that is a violation and you should report it to your Medicare Administrative Contractor or your state insurance commissioner.

Does my Medigap plan cover excess charges?

Some Medigap plans do, and some do not. Plans C, D, G, M, and N cover excess charges. Plans A, B, F, K, L, and Q do not. Check your plan documents or call your Medigap insurer to confirm what your specific plan covers.

If I see a participating provider, can they ever charge me an excess fee?

No. Participating providers sign an agreement with Medicare to accept the approved amount as full payment. They cannot charge excess fees. If a participating provider bills you an excess charge, contact your MAC when ready — this is a billing violation.

How do I report a doctor who is overcharging excess fees?

Contact your Medicare Administrative Contractor with the doctor's name, the dates of service, and copies of the bills. You can find your MAC on Medicare.gov. You can also file a complaint with your state's medical board or your state's insurance commissioner's office.