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What is limiting charge with Medicare?


Limiting charges were established by CMS to limit the amount a non-participating provider can charge a beneficiary for a non-assigned service. In other words, this is the maximum amount that non-participating providers may bill their Medicare patients on non-assigned claims. The limiting charge is equal to 115 percent of the non-participating allowance. Limiting charges only apply when a nonparticipating provider does not accept assignment.

Under public law NO. 99-509, The Omnibus Budget Reconciliation Act, there continue to be limits on the charges to Medicare beneficiaries which may be made by non-participating physicians. If a physician violates these limits, he or she may be subject to sanctions such as exclusion from the Medicare Program and/or the payment of civil monetary penalties ($10,000 for each item or service involved).

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