What is the practice of charging a Medicare beneficiary an amount in excess of the Medicare reimbursement rate for Medicare-covered services?

• A. Claim
• B. Balance Billing
• C. Concealment
• D. Complaint

Answer: (B)

Balance billing describes charging a Medicare beneficiary more than Medicare has reimbursed for a covered service. Medicare sets a payment rate for each covered service, and the provider’s charge may be higher than that rate. When the provider bills the patient for the difference between their charge and the Medicare payment (and for any remaining cost-sharing in some cases), that extra amount is balance billing. If a provider accepts assignment, they agree to Medicare’s rate as payment in full for the service and typically cannot balance bill beyond the patient’s deductible and coinsurance. If a provider does not accept assignment, they may bill above Medicare’s rate up to a certain limit, but the practice remains balance billing. This term is distinct from submitting a claim to Medicare, concealing information, or filing a complaint.