Medicare and/or Medigap Acceptance by Doctors

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More on the Balance-Billing Conundrum

By Dr. David Edward Marcinko; MBA, CMP™



In light of the large number of elderly people, hospitals and doctors often accept Medicare and Medigap coverage without charging above the fees specified by these health insurance programs [ie., do not “balance-bill”].

Other doctors however, do not accept the specified Medicare fees and charge above those fees on a “balance billing” basis (i.e., charging more for their services than the Medicare or Medigap reimbursement schedules provided).

Balance Billing Limitations

Providers are not permitted to “balance bill” more than 15 percent above the schedule amounts. In many circumstances, “balance billing” is limited even further or forbidden outright on a contractual basis with private plans, insurance companies, HMOs, MCOs, etc.

Physician Refusal

Originally, it was projected that “balance billing,” or the refusal of leading medical specialist physicians to accept Medicare for payment, would increase as Medicare fees were further reduced. This apparently did not happen during the last several years.

However, as many managed care plans and HMOs are now reimbursing physicians and other providers at fee schedules considerably below Medicare rates in 2008, this refusal may finally be emerging in some cases. But, we trust it will not be dishonestly sought through inappropriate balance billing.


A number of organizations, including the American Association of Retired Persons (AARP), assist seniors with submitting medical bills. After a major health setback, however, seniors may want to rely on health insurance claim specialists to have all their medical expenses properly and speedily processed for reimbursement.


In many cases, traditional Medicare (but not Medicare+ programs) is now the payer of choice for many physicians. And so dear colleagues; either sign-on or refuse, but play by the rules. User opinions and comments, sent to the Medical Executive-Post, are appreciated.

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Related Information Sources:

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