Check Medicare statements carefully


January 03, 1993|By JANE BRYANT QUINN

NEW YORK — New York--If you're on Medicare -- or your parent is -- check every payment statement that Medicare sends. It may save you from being overcharged.

There's a legal ceiling on what doctors can bill their older patients. But many patients do not know about it, and certain doctors simply ignore it.

The good news is that the Health Care Financing Administration, which oversees Medicare payments, is finally starting to enforce the law. That should hold down the bills that senior citizens pay.

A few doctors think they have found a loophole. They are having their patients sign waivers, agreeing to pay more than Medicare allows.

The docs are wrong. Such waivers have no legal effect, and patients cannot be bound by them, says Carol Walton, director of HCFA's bureau of program operations. This month, HCFA is expected to notify doctors that waivers are unenforceable.

The federal rules on doctor bills are clear. Medicare approves a schedule of fees, covering most insured medical procedures. It pays 80 percent of the approved bill; you pay the remaining 20 percent. Each year, you pay a deductible, before your percentage payment kicks in.

If your doctor "accepts assignment," you cannot be billed for more than the Medicare-approved fee. The feds send the doctor his or her 80 percent share and mail you an Explanation of Medicare Benefits form showing that you owe 20 percent.

Some doctors who don't generally accept assignment may do so for some patients or procedures. So ask about it every time. From July through September 1992, 84 percent of Medicare claims were filed under assignment, Walton says.

When they don't accept assignment, doctors are subject to a "limiting fee." By law, they can't bill any more than 15 percent above the charge that Medicare approves. (In 1992, the limit was 20 percent.)

Some states reject even that. Doctors must accept assignment in Pennsylvania, Massachusetts and Rhode Island and must accept it for lower-income people in Connecticut and Vermont.

How HCFA enforces the law:

(1) Doctors who don't accept assignment are supposed to receive biweekly lists of their overcharges and told to make refunds. Many over charges are inadvertent, and most doctors do give the money back.

(2) Early this year, every patient who is overcharged will be told about it. The doctor's maximum fee will be printed on the Explanation of Medicare Benefits form that you get when a Medicare claim goes through.

Here's how the fee limit works:

Say your doctor performs a service that Medicare says is worth $70. The government pays 80 percent of that amount, or $56. If your doctor accepts assignment, you'll owe $14 (your 20 percent share of the bill).

But what if your doctor bills you for $100? Your EOMB will tell you that the federal maximum allowable fee is only $80.50 (15 percent more than the $70 that Medicare approved). So you'll owe $24.50 -- $14 for your share of the Medicare payment plus $10.50 for the doctor's extra charge. The remaining $19.50 is an illegal fee that you don't have to pay. Doctors who consistently overcharge face heavy fines.

If your doctor overbills you, pay no more than the legal limit, even if you've signed a waiver. If you've already paid the overcharge, call your doctor's office and ask for a refund. Or call the carrier that processes your Medicare bills.

For more information on limiting charges, send a self-addressed, stamped envelope asking for "Medicare -- Caps on Physicians' Charges," free from the Medicare Advocacy Project, 315 W. Ninth St., Suite 1004, Los Angeles, Calif. 90015.

1992, Washington Post Writers Group

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