AVW Insurance | Medicare Guides & Free Resources

This information is for educational purposes only. Always verify current Medicare rules and coverage at Medicare.gov

Many people assume Medicare covers every dollar their doctor charges.

That’s not always the case. Medicare sets approved amounts for every covered service, but not all doctors agree to those payment limits.

When a doctor charges more than the Medicare-approved rate, the difference is called an excess charge. These extra costs can add up quickly and surprise people who thought they were fully covered.

Understanding how these charges work gives you control. You’ll know when they might apply, how to check your provider’s status, and how to protect yourself from paying more than expected.

Quick Facts

What it means: Medicare excess charges happen when a doctor accepts Medicare but not “assignment.” They can bill up to 15% more than the approved amount.

When it applies: Only under Medicare Part B services like doctor visits, labs, and outpatient care.

How to avoid it: Choose doctors who accept assignment or enroll in a Medigap Plan F or G, which covers 100% of excess charges.

What Are Medicare Excess Charges?

Medicare sets a fee schedule that determines how much it will pay for each covered medical service. Providers who see Medicare patients can either:

• Accept assignment. They agree to take the Medicare-approved amount as full payment.
• Not accept assignment. They still see Medicare patients but reserve the right to charge up to 15% more than the Medicare-approved rate.

That extra 15% is the Medicare excess charge.

Example:
If Medicare approves $100 for a visit:

• Medicare pays 80% ($80).
• You pay your 20% coinsurance ($20).
  If the provider doesn’t accept assignment, they can bill an additional $15.
  Your total payment becomes $35 instead of $20.

These charges apply only under Medicare Part B, which includes services like doctor visits, lab tests, imaging, preventive screenings, and durable medical equipment.

Why Do Some Doctors Add Excess Charges?

Doctors who don’t accept assignment usually want flexibility in pricing. They may do this for several reasons:

• Their operating costs are higher, especially in specialized or private practices.
• They prefer not to deal with Medicare’s strict payment schedules and paperwork.
• They want consistent pricing across all patients, not separate rates for Medicare and private insurance.

It’s not a sign the doctor doesn’t take Medicare — it simply means they choose not to accept Medicare’s fee as the final payment amount.

When and Where Do Excess Charges Occur?

Excess charges are legal in most states, but some states have banned or restricted them entirely. If you live in or receive care in one of these states, you’re protected:

• Connecticut
• Massachusetts
• Minnesota
• New York
• Ohio
• Pennsylvania
• Rhode Island
• Vermont

In those states, doctors who participate in Medicare must accept the Medicare-approved amount as full payment.

If you live elsewhere, you could face these charges—especially when visiting out-of-network specialists or small independent clinics. Larger health systems and hospitals typically accept assignment, but it’s always best to confirm before scheduling care.

How to Check If Your Doctor Accepts Assignment

Before scheduling a visit, check your doctor’s status:

1. Go to Medicare.gov.
2. Click “Find & Compare Doctors.”
3. Search by name or specialty.
4. Look for “Accepts Medicare Assignment: Yes.”

If it says “No,” call the office to ask about costs. You can also ask whether they charge excess fees regularly or only for certain procedures.

You can also contact 1-800-MEDICARE or your local State Health Insurance Assistance Program (SHIP) for help.

How to Avoid Excess Charges

Choose doctors who accept Medicare assignment.
Always confirm this before your appointment. A quick question to the office can prevent a surprise bill later.

Know what your Medigap plan covers.

• Plan F and Plan G both cover 100% of Medicare Part B excess charges.
• Some other Medigap plans may not include this benefit.
  If you’re unsure, review your plan summary or call your agent to verify coverage.

Stay in-network with Medicare Advantage.
Medicare Advantage plans use their own contracted networks and payment rules. You won’t face excess charges if you stay within your plan’s network.

Review your Medicare Summary Notice (MSN).
This document shows what Medicare paid and what you might owe. Compare it with your doctor’s bill to ensure there are no hidden add-ons.

Avoid out-of-state providers if possible.
Some states prohibit excess charges, while others allow them. If you travel or spend time in multiple states, ask about this before scheduling appointments.

What to Do If You Receive an Excess Charge

If If you get a bill that seems higher than expected, take these steps:

1. Call the provider’s billing office. Ask if the extra cost is an excess charge or a billing mistake.
2. Confirm their participation status. Some offices only accept assignment for certain services.
3. If valid, review your Medigap coverage. Plans F and G should reimburse you for those excess charges.
4. If you think it’s wrong, file an appeal. Contact Medicare within 120 days of the date on your Medicare Summary Notice.

You can appeal online, by mail, or by phone. Always keep copies of your bills and correspondence.

Medicare Excess Charges by State

Each state’s rules can change, so it’s best to confirm the current laws through Medicare.gov or your SHIP office.
They can also explain whether your plan covers any portion of excess fees if you’re billed.

If you move or get care while traveling, these differences can matter. Always check ahead, especially if you’re scheduling care outside your home state.

How Medigap Plans Help with Excess Charges

Medigap, or Medicare Supplement insurance, was created to fill the gaps left by Original Medicare—like deductibles, coinsurance, and yes, excess charges.

• Plan F: Covers both Part B coinsurance and all excess charges.
• Plan G: Covers everything Plan F does except the Part B deductible.
• Plan N: Does not cover excess charges; you’d pay those out of pocket.

If you see specialists or live in a state that allows excess charges, a Plan G policy can save hundreds of dollars per year.
Keep in mind that Plan F is only available to people who became eligible for Medicare before January 1, 2020.

How to Handle Bills and Stay Organized

• Keep copies of your Medicare Summary Notices (MSNs) and provider bills in one folder.
• Review them quarterly or after each new service.
• Use a simple spreadsheet or notebook to track billed amounts and what Medicare approved.
• If something looks off, call Medicare or your insurance carrier before paying.

This small habit saves time, money, and stress.

How to Plan Ahead

Even if you’ve never received an excess charge, planning ahead helps.

• Ask new doctors about their Medicare billing policy before your first visit.
• Check your Medigap plan benefits once a year during your renewal period.
• Use online resources like Medicare.gov and SHIP counselors for clarification.
• If you switch states, review your new state’s excess charge laws immediately.

These steps ensure you always know what to expect—no surprises, no confusion.

Why Most People Never See an Excess Charge

According to Medicare statistics, over 95% of providers who participate in Medicare accept assignment.
That means the vast majority of beneficiaries will never face excess charges.

Still, knowing the rules protects you. You’ll be confident that your bills are accurate and that you’re not overpaying.

Want to Go Deeper?

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It explains how to compare plans, avoid penalties, and choose the right coverage for your needs.
You’ll also find checklists and examples you can print or keep on your computer.

Final Thoughts

Excess charges under Medicare Part B are rare but important to understand.
They happen when doctors bill more than Medicare allows, and they’re completely avoidable when you know what to look for.

Always confirm your provider accepts assignment, review your coverage regularly, and stay informed through Medicare.gov. These steps protect both your wallet and your peace of mind.

This content is for educational purposes only and does not constitute official Medicare advice. I am not affiliated with Medicare or any government agency. For complete coverage options, visit Medicare.gov or call 1-800-MEDICARE.

Examples shared are general scenarios for educational purposes and do not reflect any specific individual or situation. This content does not provide plan recommendations or enrollment guidance.