I am being billed by a doctor for a balance over what my Medicare will pay, but I cannot afford to pay this amount. Am I responsible for paying?

Probably. Medicare pays only a portion of a doctor’s bill that is covered. You are responsible for paying the rest. This is called a co-payment. If you do not pay your co-payment, you are indebted to the doctor just as you would be to any other creditor. However, there are limitations on the total that a doctor may charge you. 

Doctors who treat Medicare recipients fall into two categories: participating and non-participating. Participating doctors enter into an agreement with Centers for Medicare and Medicaid Services (CMS) to follow guidelines set by Medicare. Many times a participating doctor will charge directly to Medicare and you never receive the bill. The Medicare guidelines do not allow a participating doctor to charge the patient more than the Medicare-approved charge, although you may still have to pay your co-payment amount. 

A non-participating doctor, on the other hand, is not subject to the same rules. However, Congress placed a cap on how much these doctors can charge. The cap is called a limiting charge (LC). Non-participating doctors can only charge 15% over the Medicare-approved amount for their services. If they charge more, they may be subject to sanctions by CMS. 

If Medicare does not cover the charges, and the charges are not beyond the LC, you are responsible for them. If you don’t pay, the doctor can report you to a collection agency, or even sue. If you cannot afford the co-payment, you should inform the doctor of your financial situation and make whatever payments you can. If the amount you owe is small, the doctor may not spend time or money attempting to collect. However, you cannot rely on this. You legally owe the doctor regardless of how small or large the bill may be. If the doctor does attempt to collect, neither the doctor nor a collection agency may engage in harassing conduct to collect the balance due. 

Patients should read their medical bills carefully. If a service has been provided to you that was not covered by Medicare, the doctor might have asked you to sign a waiver of liability, or Advance Beneficiary Notice (ABN), before you received the service. An ABN is a written notice that tells the patient why Medicare probably (or certainly) will not pay for a service. If you still want to get the service, you will be asked to sign an agreement that you will pay for the service yourself if Medicare does not pay for it. ABNs are used in the Original Medicare Plan, but not in Medicare managed care plans. 

For more information, see: 42 U.S.C. §§ 1395w-4, 1395w-4(g) (2015); W. Va. Code §§ 46A-2-124 to -129a (2015); 42 C.F.R. §§ 424.50, 424.53, 424.56 (2015); Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2015), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015).