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A non-participating physician provides services to a Medicare patient who has total charges of $100 (before Medicare’s limiting charge is applied).

May 6, 2024

A non-participating physician provides services to a Medicare patient who has total charges of $100 (before Medicare’s limiting charge is applied). The physician does not accept assignment, charges the maximum allowable, and submits the claim to Medicare. Assume Medicare’s approved schedule for these services is $80.
- What is the maximum amount the physician is allowed to charge the patient?
- What is the Medicare portion of the physician payment (which Medicare sends to the patient)?
- What is the patient’s portion of the payment to the physician (net of the reimbursement from Medicare in the previous question)?
- Would the physician have been better off by accepting assignment on this case? Why or why not?
How do a high percentage of Medicaid (not Medicare) patients influence a hospital’s prices?

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