What is the limiting charge in reference to non-participating healthcare professionals?

The limiting charge for non-participating healthcare professionals is established by Medicare guidelines to ensure that these providers do not bill beneficiaries more than a certain percentage above the Medicare allowable amount for their services.

The correct answer indicates that the limiting charge can be set at 115% of the maximum billed charge. This means that a non-participating provider is permitted to charge up to 115% of the Medicare fee schedule for their services. This is significant because it protects patients from being charged excessively while still allowing providers to receive fair compensation for their services.

Understanding this concept is crucial for medical coders and billers as it impacts billing practices. Correctly applying the limiting charge rules ensures compliance with Medicare regulations, which can help prevent audits and potential penalties for overcharging. Recognizing the parameters of what non-participating providers can charge is an essential part of ensuring proper billing and patient communication.