Last Modified: 12/15/2017 Location: FL, PR, USVI Business: Part A, Part B
Limiting charge provisions
Q: What happens if I bill more than the limiting charge?
A: There are potential civil monetary penalties for violating the Medicare limiting charge. The limiting charge applies to non-participating providers in the Medicare Part B program when they do not accept assignment and the beneficiary is not responsible for any billed amounts in excess of the limiting charge for a covered service.
The Social Security Act Amendments of 1994 state that non-participating physicians, other practitioners, or suppliers are held liable for charges that exceed the Federal limiting charge on services to which they apply. If such a physician, other practitioner, or supplier willfully, knowingly, and repeatedly exceeds the limiting charge, then they may be subject to a civil monetary penalty of up to $10,000 per violation, plus three times the amount of the charges claimed for each violation. In addition, the physician, other practitioner, or supplier may be excluded from the Medicare program for up to five years. This amendment is effective for services rendered on or after January 1, 1997.
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Sources: CMS internet-only manual (IOM) Publication 100-04 Medicare Claims Processing Manual Chapter 1, Section 22.214.171.124
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