Your Health

What Is the Medicare-Approved Amount?

If you are eligible and enrolled in a Medicare plan, it is necessary to understand the term Medicare-approved amount. In general, it is the fee that Medicare determines as how much a supplier or provider should be paid for their specific item or service. This amount can vary among different items and services. As Medicare Part A comes with its own pricing structure, the Medicare-approved amount usually refers to most services in Medicare Part B. The next sections will explain more about this concept.

Two Main Types of Medicare Providers

Before learning more about Medicare-approved amount, we need to understand the difference between participating and nonparticipating providers. [1]

Participating Provider

Participating providers are doctors or healthcare suppliers who accept Medicare assignments. It means that the Medicare-approved amount can be accepted as full payment even when this amount is less than the charged amount by the doctor or supplier for their services or items. Certain conditions should be met when a healthcare supplier or doctor accepts assignment:

– Out-of-pocket expenses should be lower

– Providers should send a claim to Medicare directly and not charge for claim submission

– Providers only charge you for the Medicare coinsurance and deductible [2]

Nonparticipating Provider

Nonparticipating providers are doctors or healthcare suppliers who do not accept Medicare assignments. They would accept some but not all Medicare-covered services. In many cases, if doctors or healthcare suppliers do not accept Medicare-approved amount for items or services as full payment, they are still considered to be nonparticipating providers. Some conditions would be applied to these providers:

– Initially, you need to pay the costs in full when getting the service or item.

– The doctor or healthcare supplier cannot charge you for a claim submission, but can send a claim directly to Medicare.

– You can ask the provider or doctor to send a claim.

In certain cases, the amount charged by nonparticipating providers may be up to 15 percent higher than the Medicare-approved amount. You are responsible for paying this difference. [3]