Balance billing under Medicare: protecting beneficiaries and preserving physician participation

Medicare's experience with balance billing provides valuable lessons for policy making for national or state health care reform. Medicare developed several policies to encourage physicians to become participating providers who accept Medicare-allowed charges as payment in full. Only nonparticipating physicians are permitted to bill for additional amounts beyond that paid by Medicare, and there are limits on the amount of balance billing per claim. As shown by the analysis of claims presented in this article, Medicare has successfully provided financial protection to beneficiaries. In 1986, more than 60 percent of expenditures for physician services were on assigned claims for which there could be no balance billing; by 1990, 80 percent of expenditures were on assigned claims. Balance billing decreased by about 30 percent during the same period. Although these policies have been successful in reducing total expenditures for balance billing, they may not provide financial protection to the most economically vulnerable beneficiaries. Using survey and claims data, we found that the poor have lower balance billing expenditures for services provided by primary care physicians, but that there is no relationship between poverty status and balance billing expenditures for services of nonprimary care physicians. In addition, most low-income beneficiaries are liable for balance bills. Under health care reform, adoption of Medicare's incentive-based approach with mandatory assignment for the poor would allow for some choice based on price and would provide financial protection for all consumers.