Medicare balance billing is when a provider bills you for more than the Medicare-approved amount plus your deductible and coinsurance. It isn't allowed when the provider accepts assignment, and it isn't allowed for Medicare cost sharing if you're in the Qualified Medicare Beneficiary (QMB) program. A provider who doesn't accept assignment can balance bill for most covered services, but only up to the "limiting charge," which Medicare.gov says generally can't be more than 15% above the approved amount.
What does balance billing mean?
Medicare sets an approved amount for each covered service. Normally, Medicare pays its share and you pay your deductible and coinsurance. Balance billing is any amount a provider charges you beyond that.
Whether a provider can do it depends on their relationship with Medicare. Medicare.gov explains three kinds of providers.
When is balance billing not allowed?
When the provider accepts assignment. Medicare.gov says a provider who accepts assignment agrees to take the Medicare-approved amount as full payment for covered services. They can charge you only your deductible and coinsurance.
When you're in QMB. Medicare.gov says if you qualify for the QMB program, Medicare providers aren't allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments.
When you're in a Medicare Advantage plan and use network providers. In our reading, in-network providers have agreed to work with your plan, so you'd generally expect to owe only the cost sharing listed in your plan's documents. If a network bill is higher, ask your plan. Out-of-network rules differ by plan type.
When is balance billing allowed?
Non-participating providers who don't accept assignment. They can charge more than the approved amount for most covered services, up to the limiting charge. Medicare.gov says in many cases, the charge can't be more than 15% above the Medicare-approved amount, and the limiting charge applies only to certain Medicare-covered services. You may also have to pay the full amount at the time of service and wait for Medicare to send you its share.
Providers who opted out of Medicare. These providers don't work with Medicare at all. If you sign a private contract with one, Medicare.gov says you pay the full amount, and neither Medicare nor Medigap pays. The private contract doesn't apply to emergency or urgent care. See bills from doctors who opted out of Medicare.
How can I tell if I've been balance billed?
Compare the bill with your Medicare Summary Notice (MSN). The MSN lists the "maximum you may be billed" for each service. That's the number to check. What "maximum you may be billed" means explains each column.
Before calling it balance billing, review the bill closely for other mistakes:
- Was Medicare billed at all? If not, the bill may show the provider's full charge.
- Has Medigap paid yet? Some bills go out before secondary insurance processes.
- Is anything listed twice?
- Is the date or service wrong?
A high bill can come from a simple error. Either way, the next step is the same: call and ask.
What do I do if the bill is higher than it should be?
Step 1: Find out the provider's status. Ask: "Do you accept Medicare assignment for this service?"
Step 2: Compare. If they accept assignment, the bill shouldn't be more than the "maximum you may be billed" on your MSN. If they don't accept assignment, check that the charge stays within the limiting charge.
Step 3: Call the billing office.
Script if the provider accepts assignment:
"My Medicare Summary Notice for [date] shows the maximum I may be billed is $[amount], but your bill is $[amount]. You accept Medicare assignment, so can you correct the bill to match the Medicare notice and send me a new statement?"
Script if you're in QMB:
"I'm in the QMB program. My Medicare notice shows it, and I have my Medicaid card. Medicare providers aren't allowed to bill me for Medicare deductibles, coinsurance, or copays. Please remove those charges and update my account so it doesn't happen again."
Script if the provider doesn't accept assignment:
"Can you tell me the Medicare limiting charge for this service? My bill seems higher than the limiting charge would allow. Can you check it and send a corrected statement?"
Step 4: Get help if it isn't fixed. Call 1-800-MEDICARE (1-800-633-4227). A State Health Insurance Assistance Program (SHIP) counselor can also help for free.
For more examples, see what to do when a doctor bills you more than Medicare allows.
How can I avoid balance bills?
- Before a visit, ask: "Do you accept Medicare assignment?"
- If you're in QMB, show your Medicare and Medicaid or QMB cards every time.
- If you have Medicare Advantage, check that the provider is in your plan's network.
- Don't pay a bill until it matches your MSN or EOB.
Does Medigap cover balance billing?
Medicare.gov's Medigap plan comparison shows that some Medigap plans cover Part B "excess charges," which are amounts up to the limiting charge from providers who don't accept assignment. Check your plan's benefits. Medigap plans: what they pay has the details.
Frequently asked questions
What is Medicare balance billing?
It's when a provider bills you more than the Medicare-approved amount plus your deductible and coinsurance.
Is balance billing allowed under Medicare?
Not by providers who accept assignment. Providers who don't accept assignment can balance bill for most covered services, up to the limiting charge.
What is the Medicare limiting charge?
Medicare.gov says in many cases, the charge can't be more than 15% above the Medicare-approved amount for non-participating providers.
Can I be balance billed if I'm in QMB?
Medicare providers aren't allowed to bill QMB members for Medicare deductibles, coinsurance, or copays on covered services.
Not sure if you've been balance billed?
Bill Review Coach is a monthly medical bill review service for seniors and their families. Upload your first bill free, no card needed. Snap a photo of the bill and your Medicare notice, and you'll get back a plain-English summary of whether the amount looks right, what may be wrong, and what to say when you call. Refer a friend and you both get a free month once they join the paid plan. You make the calls and write the emails; we help you know what to say.
General information, not legal advice. Check your own bill and notices.