Understanding Medicare Overcharge Measures: AKA MOM States

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If you have Original Medicare and received a bill for more than the 20% you thought you would owe, you may have been overcharged. The question is, are you liable for this excess charge?

That depends on who your provider is and which state you live in.

This article will discuss Medicare assignment, Part B excess charges, and Medicare Overcharge Measures.

What is a Medicare assignment?

Medicare assignment is a process in which doctors and healthcare providers agree to accept the amount of money that Medicare pays them as payment-in-full for services provided. This means they will not bill you anything above what your insurance company has already agreed to pay. This applies to procedures covered under Medicare Part B.

What is covered under Medicare Part B?

Medicare Part B is the component of Original Medicare that covers outpatient care, such as doctor visits and preventive care.
The following are some of the services covered by Part B:

  • most vaccines
  • diabetes and cancer screenings
  • emergency room services
  • mental health care (inpatient, outpatient, and partial hospitalization)
  • ambulance services
  • durable medical equipment (DME)

What are overcharges in Medicare?

Medicare overcharges related to your Medicare Part B coverage. You may also hear them referred to as “excess charges.” These occur when providers bill you for more than what Medicare has agreed to pay them.

Not accepting Medicare assignments might cause providers to bill you for excess charges. The Part B Excess Charge is the amount exceeded by Medicare allowance.

For example, let’s say you go to the doctor and have a Medicare-approved procedure that costs $800 (according to Medicare.)

If that doctor does not accept Medicare assignment, they can decide that $800 is not sufficient reimbursement for that test. The doctor can choose to charge 15% more, which would amount to $120 ($920 total) for the test. This $120 is considered the Part B excess charge.

Senior author worried that she might be getting overcharged on Medicare
This means doctors are not permitted to charge a patient any Part B extra fees.

What are Medicare Overcharge Measures?

There are a few states that have enacted the MOM Law (Medicare Overcharge Measure). This means doctors are not permitted to charge a patient any Part B extra fees.
Current states with the MOM Law are:

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

I don’t live in a state with the MOM Law. How can I make sure to avoid Part B excess charges?

Fortunately, Part B excess charges are not common. There are just 5% of doctors in the United States that do not accept Medicare assignments.

There are two ways you can be sure to avoid Medicare overcharges if you do not live in a state that has imposed the MOM Law.

1st. Verify your provider’s Medicare assignment directly with Medicare

You can search the database on Medicare.gov to find out if your provider accepts Medicare assignments.

Remember, if you are having surgery, there may be multiple providers involved. Make sure to know who everyone on your care team is so that you can look them all up individually.

2nd. Enroll in a Part C Medicare Advantage plan or a Medigap plan that will pay for excess charges.

Depending on the plan you choose, you may be able to get all or some of the excess charges paid for. As of 2021, Medigap Plan F and Plan G pay for all excess charges.

My provider’s office said they accepted Medicare patients, but now I’m getting a Part B excess charge. Did they lie to me?

Accepting Medicare patients and Medicare assignment isn’t the same thing, though it would have been more forthright for your provider’s office to explain that to you.

The provider may still charge you an extra 15% for services.

If your visit costs $200, you will pay the 20% leftover from Part B. (This is assuming you have no supplemental or Part C coverage.) You are left with paying $40. However, your provider can choose to add 15% of the total charges to your bill, leaving you with a total of $70 to pay out-of-pocket.

Your chance of incurring a Medicare overcharge is meager. However, it is good practice to do your due diligence when choosing a healthcare provider. Medical bills can add up quickly, so it is essential to save on expenses when possible.

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Justin Brock

President & CEO of Bobby Brock Insurance