What Part B Excess Charges Are

Part B excess charges are amounts that doctors and other healthcare providers can bill you above what Medicare pays them. When a provider does not accept Medicare's approved amount as full payment, they can charge you the difference — and that difference is the excess charge.

Medicare sets an approved amount for each service. Your doctor can either accept that amount as payment in full, or they can charge more. If they charge more, you pay the overage out of your own pocket, on top of your regular Part B deductible and coinsurance.

Not all doctors charge excess amounts. Many accept Medicare's approved amount as full payment. But some providers — particularly specialists and those in high-cost areas — do bill the excess, and the amount can add up quickly.

Key Takeaways

  • Part B excess charges are amounts above Medicare's approved payment that non-participating doctors can bill you directly.
  • Participating doctors agree to accept Medicare's approved amount as full payment and cannot charge you the excess.
  • Excess charges are capped at 15 percent above Medicare's approved amount, but you still pay them out of pocket.
  • You can check whether a doctor participates in Medicare before your visit using the Medicare provider search tool.
  • Medigap plans (supplemental insurance) may cover some or all of your excess charges, depending on the plan.

Participating Versus Non-Participating Doctors

The key difference is whether your doctor is a participating provider or a non-participating provider. Participating doctors sign an agreement with Medicare to accept the approved amount as full payment. They cannot bill you for the excess, no matter what.

Non-participating doctors have not signed that agreement. They can charge above Medicare's approved amount. However, federal law limits how much they can charge: the excess cannot exceed 15 percent above what Medicare approves. So if Medicare approves $100 for a service, a non-participating doctor can charge up to $115.

Even with that 15 percent cap, the charges add up. If you see a non-participating specialist several times a year, excess charges can become a significant cost.

How Excess Charges Appear on Your Bill

When you receive a bill from a non-participating doctor, you will see the Medicare-approved amount listed separately from the excess charge. Your provider sends the claim to Medicare, Medicare pays its share (usually 80 percent of the approved amount after your deductible), and you receive a bill for both your coinsurance and the excess charge.

For example: if a doctor charges $150 for a service and Medicare approves $100, Medicare pays $80 (80 percent of the approved amount, assuming you have met your deductible). You owe $20 in coinsurance (20 percent of the approved amount) plus $50 in excess charges — a total of $70 out of pocket.

You should always ask for an itemized bill so you can see exactly what you are being charged and verify that the excess does not exceed the 15 percent limit.

Finding Out Whether Your Doctor Charges Excess Amounts

The best way to avoid surprise excess charges is to know your doctor's status before you go. Use the Medicare Provider Search tool on Medicare.gov. Enter your doctor's name and location, and the search will tell you whether they are a participating or non-participating provider.

If your doctor is non-participating, you can ask their office directly whether they charge excess amounts and what the typical excess is for common services. Some non-participating doctors choose not to charge the full 15 percent allowed, so it is worth asking.

If you are establishing care with a new doctor, ask about their Medicare participation status when you schedule your first appointment. This is a routine question and offices expect it.

How Medigap Plans Handle Excess Charges

If you have a Medigap supplemental insurance plan, your coverage of excess charges depends on which plan you own. Some Medigap plans cover excess charges in full; others cover them partially; and some do not cover them at all.

Plans F and G historically covered excess charges completely, which made them popular choices. However, Plan F is no longer sold to people new to Medicare as of 2020. Plan G still covers excess charges for most beneficiaries, though the rules vary slightly by state.

If you have a Medigap plan, check your policy documents or call your plan to confirm what excess charges, if any, are covered. This information is also listed in your plan's Summary of Benefits, which you received when you enrolled.

What to Do If You Receive an Excess Charge Bill

If you receive a bill with an excess charge and you believe it is incorrect, first verify that the excess does not exceed 15 percent of the Medicare-approved amount. You can check the approved amount on your Medicare Summary Notice, which Medicare sends to you after processing a claim.

If the excess exceeds 15 percent, contact your doctor's billing office and ask them to correct it. If they do not respond, you can file a complaint with your state's Medicare Administrative Contractor (MAC), which handles billing disputes in your region. You can find your MAC's contact information on Medicare.gov.

Keep copies of all bills and correspondence. If you have Medigap coverage, also contact your supplemental plan to ask whether they will cover the excess charge and what documentation they need from you.

Strategies to Minimize Excess Charges

The most straightforward approach is to use participating doctors whenever possible. They cannot charge excess amounts, so your costs are more predictable. When you need a specialist, ask your primary care doctor for a referral to a participating provider in your area.

If you do see a non-participating doctor, ask for an estimate of charges before your visit. Many offices can tell you what they typically charge for a specific service, which helps you budget and decide whether to seek a second opinion from a participating provider.

If excess charges are a regular concern for you, consider whether a Medigap plan that covers excess charges (such as Plan G in most states) might be worth the monthly premium. The math depends on how often you see non-participating doctors and how much they charge.

Frequently Asked Questions

Can a doctor charge me more than 15 percent above Medicare's approved amount?

No. Federal law caps excess charges at 15 percent above the Medicare-approved amount. If a provider charges more, that is a billing error. Report it to your state's Medicare Administrative Contractor or file a complaint with your state's medical board.

If I have Medicare Advantage, do I have to pay excess charges?

Medicare Advantage plans have different rules than Original Medicare. Most Medicare Advantage plans do not allow excess charges at all — participating doctors in the plan's network must accept the plan's payment as full payment. Check your plan documents or call your plan to confirm.

Does Medicare Part B cover the excess charge?

No. Medicare pays its share of the approved amount only. You are responsible for the excess charge unless you have supplemental insurance (Medigap) that covers it. The excess is your financial responsibility.

How do I know if my doctor is participating in Medicare?

Use the Medicare Provider Search tool at Medicare.gov, or call your doctor's office and ask directly. Participating doctors will tell you they accept Medicare assignment, which means they accept the approved amount as full payment.

What if I cannot afford the excess charges?

Talk to your doctor's billing office about payment plans or financial hardship programs they may offer. You can also look into whether you may have access to for Medicare Savings Programs, which are state-run programs that help low-income beneficiaries pay Medicare costs. Contact your state Medicaid office for information.