About the Medicare Fee Schedule

Pamela Cannaday by Pamela Cannaday | Licensed since 2011
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This article was updated on: 09/16/2018

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If you review your Medicare Summary Notices, you may see that the “Amount Charged” by your Medicare provider may not be the same amount as the “Medicare Approved” charge. This is because Medicare only approves the amount listed in the Medicare fee schedule for each particular type of Medicare service.

The Medicare fee schedule is a complete comprehensive listing of the fee maximums used by Medicare to pay contracted providers and suppliers for their services and products. This includes doctors, institutions, medical equipment suppliers, and other providers and suppliers. The Centers for Medicare and Medicaid Services (CMS) is responsible for setting the Medicare fee schedule. This is done through federal legislation, and it can change from year to year.

Effect on Medicare cost sharing
The Medicare fee schedule doesn’t directly affect your Original Medicare premiums, deductibles, or copayments. However, it may affect the amount you pay for services that have a coinsurance. For example, if you see a specialist, and he or she bills Medicare $150.00 for the services. Medicare will pay 80% of their fee schedule amount.  You will be responsible for paying 20%. Let’s say in this example that the Medicare fee schedule amount is $100, you will have to pay $20.

Effect on provider choice

Doctors have a few options when it comes to the Medicare program. They have the choice of being either a participating or non-participating physician, or they have the choice to completely opt out of the program.

A participating physician agrees to accept the Medicare-approved charge as full payment for services. This is also known as accepting assignment. A non-participating physician can determine on a case-by-case basis whether she or he will accept the Medicare-approved charge in the Medicare fee schedule. If a non-participating doctor chooses not to accept assignment, the doctor can charge up to 15% more than the Medicare-approved cost of services provided. Physicians who opt-out of the Medicare system cannot bill Medicare or other Medicare private insurance plans for services. Instead, the entire bill is the responsibility of the patient.

I hope you understand the Medicare fee schedule a bit better now. If I can answer any other questions for you, please reach out to me. Learn more about me, see my photo, and view my profile using the “View profile” link below. Or, use one of the links below to request a phone conversation or an email with personalized information for you. If you want to compare Medicare plans for your health needs and budget, go to the Compare Plans buttons on this page and click on it.

 

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