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Medicare and Surprise Medical Bills

Have you ever been confused by an Explanation of Benefits statement from your health insurance company or received surprise medical bills?  Between premiums, deductibles, coinsurance, in- network vs. out-of-network charges and covered vs. non-covered services, understanding the fees you owe for your care can be a challenge whether you have Medicare or private health insurance.

Unexpected medical bills may occur in a few different ways.

Reimbursement rates for Original Medicare are set by the federal government. Health care providers are not required to participate with Original Medicare, although most choose to do so.  Participating providers must accept Medicare reimbursement as full payment for services, even though the reimbursement rate is lower than the amount which the provider charges. Copayments, deductibles, and coinsurance may still apply.

Some providers choose not to participate in Medicare, although they will accept Medicare payments.   Surprise bills occur when these providers practice balance billing, in which Medicare allows them to charge patients up to 15% more than the Medicare reimbursement rate for a particular service.  Patients are then billed for the difference (in addition to the normal copayment and coinsurance). 

For example, if the Medicare rate for a service is $100, Medicare will pay a participating provider 80% or $80, and the patient is responsible for 20% or $20. A non-participating provider is only eligible to receive 95% of the Medicare rate ($95) but tacking on the additional 15% increases the patient’s responsibility to $33.25 in this example.

Providers who have opted out of Medicare may not seek reimbursement from Medicare at all. These providers set their own fees and patients must pay privately if there is no other insurance coverage.  A list of providers who have chosen to opt out of Medicare is available on the Centers for Medicare and Medicaid Services website:  A review of this list revealed that most of the providers in Central PA who have opted out of Original Medicare practice in the fields of dentistry, oral surgery, psychiatry, and psychology. A handful of internal and family medicine practitioners are also included on this list.  

Surprise medical bills may also occur with Medicare Advantage plans. These plans generally have fewer participating providers than Original Medicare.  Participating providers are considered in-network, while non-participating providers are out-of-network. An individual’s out-of-pocket costs are lower when services are provided in-network.

However, assumptions cannot be made about a provider’s participation in a specific plan. When emergency care or in-patient hospitalization is necessary, a hospital may be listed as in-network for a particular plan, but all of the physicians working in that hospital may not necessarily be in-network. Thus, a patient may inadvertently receive out-of-network care when services were believed to be in-network.

Several states have passed laws which address surprise medical bills, and a few bills have been introduced in Congress as the federal government also considers this issue.  Pennsylvania currently has very limited protections against surprise medical bills. 

When receiving medical care, it may not be enough to check if a care facility or a specific physician participates in Original Medicare or a certain Medicare Advantage plan.  If specialty care is recommended or even diagnostic testing, verification of every provider’s participation is necessary in order to avoid any surprises.

Karen Kaslow, RN, BSN