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If Your Health Care Provider Accepts Medicare, Can You Be Billed For The Balance?

I’m Katelyn Holub, an attorney focusing on personal injury law in northwest Indiana.

Welcome to Personal Injury Primer, where we break down the law into simple terms, provide legal tips, and discuss topics related to personal injury law.

Today’s question comes from a caller who would like to know “if you have an injury claim and your health care provider accepts Medicare, can you be billed for the balance?”

If Medicare pays a portion of your injury related medical expenses, can your doctors and other healthcare providers collect their outstanding balances in full when you settle your third party claim for personal injuries? To answer this question, a distinction must first be made between Medicare Part A and Part B benefits. Medicare Part A generally will pay for in-patient hospital care, care in a skilled nursing facility following a hospital stay, home health care, and hospice care. Medicare Part B pays for medical services and supplies, and it helps to pay doctors’ bills. Also, Medicare Part B generally applies to cover out-patient hospital treatment, as well as x-rays and other diagnostic and laboratory tests. Part B also applies to ambulance needs, ambulatory surgical services, physical and occupational therapy, speech therapy, pathology studies, out-patient mental health care, and limb braces. Certain durable medical equipment, including wheelchairs, walkers, hospital beds, artificial limbs and eyes, and medical supplies such as ostomy bags, splints and casts, are also covered under Medicare Part B.

Generally, physicians and other healthcare providers and medical suppliers who accept “assignment” of Medicare, agree to accept the Medicare “allowed” amount for a particular service or supply as full payment under Medicare Part B. Medicare usually pays 80% of the “allowed” amount directly to the provider after the Medicare beneficiary meets the annual Part B deductible of $100.00. Thereafter, the beneficiary can be only asked to pay the remaining 20% of the “allowed” charge. In other words, after accepting Medicare payments, the provider cannot charge, or “balance bill” the patient for more than the 20% coinsurance amount. However, the provider can bill the patient for services or supplies deemed not covered by Medicare, in addition to the $100 Medicare deductible, and in addition to the 20% co-pay on allowed charges.

Consequently, and most importantly, if a Part B health care provider has accepted assignment of Medicare, anything above the Medicare “allowed” amount for the medical service may not normally be balance billed to the patient. Thus, a provider may not accept payment from Medicare, and then seek to recover more than 20% of the Medicare-approved amount from the patient. This is true even if the doctor, hospital, or other health care provider would normally charge (or did initially bill the patient for) more than the Medicare “allowed” amount.

The above general statement of law may not be applicable to every case. If you have questions, please phone one of our attorneys for case specific advice.

I hope you found this information helpful. If you have questions about your legal rights if you get hurt due to the carelessness of another person, or as a result of substandard medical care, or due to a product defect, construction injury, or any other type of personal injury, please give us a call at (219) 736-9700. You can also learn more about us by visiting our website at www.DavidHolubLaw.com – while there make sure you request a copy of our book “Fighting for Truth”.