How is the total financial liability calculated for a patient with Medicare who sees a nonparticipating physician?

The total financial liability for a patient with Medicare who sees a nonparticipating physician is calculated by factoring in limiting charges and coinsurance. Nonparticipating physicians are allowed to charge up to 115% of the Medicare fee schedule for their services, which is known as the limiting charge. However, Medicare only pays a portion of the allowable charges, and the patient is typically responsible for coinsurance (20% of the Medicare-approved amount) and any excess charges that go above the limiting amount.

In this case, the patient's financial responsibility includes not just the coinsurance but also any additional charges that exceed the Medicare-approved amount. Since nonparticipating providers can charge more than the standard fee schedule, it's crucial to account for both the limiting charges that set the maximum fee they can bill and the coinsurance that applies to the payment made by Medicare. This comprehensive approach is necessary to arrive at an accurate figure of what the patient ultimately owes.