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What is the Limiting Charge (Health Care) and Its Implications?
Definition & Meaning
The limiting charge in health care refers to the maximum fee that a non-participating physician can charge a Medicare beneficiary for medical services rendered. Specifically, it is the highest amount a doctor, who has not accepted Medicare assignment, can bill for a service that Medicare covers. This charge is capped at 15 percent above the amount that Medicare has approved for that service. However, it is important to note that the limiting charge does not apply to all services; for instance, it does not cover medical supplies or equipment.
Table of content
Legal Use & context
The concept of limiting charge is primarily used in the context of Medicare and health care law. It is relevant for both patients and healthcare providers, particularly in understanding billing practices. Users may encounter this term when dealing with medical billing disputes or when seeking to understand their rights as Medicare beneficiaries. Legal forms related to health care billing and Medicare rights can often be found through resources like US Legal Forms, which provide templates drafted by attorneys.
Key legal elements
Real-world examples
Here are a couple of examples of abatement:
Example 1: A non-participating physician provides a service that Medicare has approved for $100. The physician can charge the patient a maximum of $115, which includes the 15 percent limiting charge.
Example 2: A patient receives a bill for a medical supply that is not covered under the limiting charge rules. In this case, the physician can charge any amount they choose, as the limiting charge does not apply. (hypothetical example)
Comparison with related terms
Term
Definition
Difference
Medicare Assignment
An agreement where a physician accepts the Medicare-approved amount as full payment.
Limiting charge applies only to non-participating providers who do not accept assignment.
Allowed Amount
The maximum amount Medicare will pay for a covered service.
Limiting charge is based on the allowed amount but includes an additional percentage for non-participating providers.
Common misunderstandings
What to do if this term applies to you
If you are a Medicare beneficiary and receive a bill that exceeds the limiting charge, you should first verify the service and the amount billed. If you believe the charge is incorrect, you can contact the physician's office for clarification. You may also consider using legal forms from US Legal Forms to address billing disputes or to understand your rights better. If the issue remains unresolved, seeking assistance from a legal professional may be necessary.
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