A Medicare non-participating (non-PAR) provider's approved payment amount is $200 for a lobectomy and the deductible has been met. Which of the following amounts is the limiting charge for this procedure?

A Medicare non-participating (non-PAR) provider's approved payment amount is $200 for a lobectomy and the deductible has been met. Which of the following amounts is the limiting charge for this procedure?

• A. $230
• B. $200
• C. $215
• D. $250

Answer: (A)

Limiting charge is the maximum a non-participating Medicare provider can bill a beneficiary for a covered service. For non-PAR physicians, this cap is 115% of the Medicare-approved amount. With an approved amount of $200, the limit is 200 × 1.15 = $230. The deductible being met affects how much the patient still owes in coinsurance, but it does not change the limiting charge. So the maximum amount the non-PAR provider could bill for this lobectomy is $230.

Limiting charge is the maximum a non-participating Medicare provider can bill a beneficiary for a covered service. For non-PAR physicians, this cap is 115% of the Medicare-approved amount. With an approved amount of $200, the limit is 200 × 1.15 = $230. The deductible being met affects how much the patient still owes in coinsurance, but it does not change the limiting charge. So the maximum amount the non-PAR provider could bill for this lobectomy is $230.