If a nonparticipating physician does not accept assignment, how much might the patient be liable for if the total charge is $250.00?

When a nonparticipating physician does not accept assignment, they are allowed to charge patients for the full amount of the services rendered. In this scenario, the total charge is $250.00.

Patients typically have cost-sharing responsibilities that include coinsurance and deductibles based on the allowed amount determined by the patient's insurance plan. Nonparticipating physicians may charge more than the allowed amount set by Medicare or other insurance plans, but there are limits to how much they can charge over the allowed amount, known as the non-participating provider's fee schedule.

If the patient has a coinsurance responsibility and a deductible that has already been met, the patient is liable for the difference between the allowed amount and the amount the insurance pays, which can significantly contribute to the overall cost they have to cover.

In this case, the patient might only be expected to pay a percentage of the allowed amount instead of the full $250. When factoring in the insurance allowed amount and the patient’s coinsurance responsibility, the amount they might owe would be calculated to be $66.50. This amount represents the patient's out-of-pocket liability after considering the insurance coverage adjustments.

Understanding the billing process, how nonparticipating providers can charge, and patient financial responsibility is essential