A Medicare beneficiary sees a physician who does not participate in Medicare and does not accept assignment. Which statement is correct?

Why C is correct

Participating physicians accept assignment, meaning they accept Medicare's approved amount as payment in full and bill only the 20% coinsurance. Non-participating physicians may balance bill the beneficiary above the approved amount, but the excess is capped by the limiting charge, so they cannot charge an unlimited amount. This difference in payment responsibility between participating and non-participating providers is the core of the assignment concept. Nonparticipating physicians may choose per claim whether to accept assignment. When they do not, the beneficiary pays the difference between the approved amount and the actual charge, capped by the limiting charge of 115 percent of the nonparticipating fee schedule amount, and Medicare reimburses 80 percent of the approved amount after the deductible.

Why the other options are wrong

• D) Medicare pays 80% of the approved amount after the deductible, never 100% of a provider's billed charge. Medicare never pays 100 percent of a physician's full billed charge; it pays its approved amount subject to the deductible and coinsurance.
• A) Beneficiaries owe cost sharing, and non-participating providers may additionally bill up to the limiting charge. The beneficiary does owe amounts after Medicare pays: the coinsurance and, for nonparticipating providers, balance billing up to the limiting charge.
• B) Accepting the approved amount as payment in full describes participating providers who accept assignment, not this physician. Only participating physicians agree to accept Medicare's approved amount as payment in full; nonparticipating physicians make that choice case by case.

Memory hook

Assignment = doctor takes Medicare's price. No assignment = patient may see a balance-billing bill.