Coverage For Services Under Part B
Medicare has specific coverage rules and limitations regarding what it will pay for and to whom. Generally, an approved Medicare physician must agree to an "assignment" of Medicare. This means that the physician agrees to charge only what the Medicare schedule provides as to any given medical treatment or surgery. The physician must also agree not to bill you more than Medicare's covered limits. Finally, the physician must agree to bill Medicare directly, rather than the patient.
If you receive services from a physician under "assignment," then Medicare will pay 80% of the covered charges, so long as they are approved by Medicare. Medicare will then pay the physician the 80%. You are responsible for payment of the remaining 20%, which must be paid from either other supplemental insurance, or your personal assets.
Physicians themselves make the choice of whether to accept an assignment from Medicare. Medicare has a list of "approved physicians" and if it is possible, before agreeing to have extensive treatment, it would be wise to consult the Medicare list of physicians. Also, some insurance companies are providers for the Part B Medicare coverage, and they may also have a list of approved providers. It would even be wise to request a statement from your physician, wherever possible, that certain charges will be guaranteed. All of this extra preparation at the outset will greatly lessen the legal issues which may arise after the services are rendered.
When a physician does not accept an assignment from Medicare, the patient must pay the physician directly. Medicare will then determine the covered charges under its schedule and, if they approve the charges which you incurred, they will pay you 80% of the covered charges [not necessarily equal to 80% of the amount you were charged.]
Additionally, you should check with Medicare rules, since they impose a limit on physicians as to the amount they can charge, even if they do not agree to an "assignment." This amount is currently 15% above the Medicare fee schedule of approved charges. Your state may also regulate this "cap" on the amount of fees a physician can charge, when they are not agreeing to an "assignment."
Obviously a number of issues and potential "disputes" over coverage can arise. Shortly, we will discuss the procedural aspects of the Medicare system when a "dispute" arises.
Medical or Diagnostic Tests Under Part B
Even if your physician is not an approved Medicare provider, certain tests which he/she may prescribe are still covered by Medicare. Naturally, the testing center or facility must be a Medicare-approved provider and must agree to accept charges on assignment from Medicare, under a process similar to that set forth in the above section. With the exception of certain state limitations, Medicare will generally pay 100% of these approved diagnostic tests, so long as they are prescribed.
Once again, by asking the physician ahead of time, you can determine which tests he/she will be scheduling and make certain that even if the physician is not approved, that he/she prescribes to a testing or diagnostic center which is approved, and make certain that the tests prescribed are covered under Medicare schedules.