Billed more than the “maximum you may be billed”? What it means and what to do
By the Folkswise team · Updated · 5 min read · How we write these guides
Every Medicare Summary Notice has a column called “Maximum You May Be Billed.” It's the most a provider can ask your parent to pay for that service. When a bill asks for more, there's usually a reason you can fix with one phone call.
First, match the bill to the notice
- Find the same provider and date of service on the Medicare Summary Notice (MSN).
- Compare the bill's “amount due” with the MSN's “Maximum You May Be Billed” for that line, or for all the lines from that visit added together.
- Check the bill's date. If it was printed before Medicare processed the claim, it may not show Medicare's payment yet.
Why the bill can be higher
- The bill went out before Medicare paid, so it shows the full list price. A corrected bill usually follows.
- Medicare's payment, or the provider's required discount, wasn't applied to the account.
- Your parent's other insurance (Medigap, Medicaid, a retiree plan) wasn't billed, or hasn't paid yet.
- Your parent is in QMB or has full Medicaid, which generally means they can't be billed for Medicare deductibles, coinsurance or copays at all.
- It's a simple mistake: the wrong patient, a duplicate charge, or a service your parent didn't get.
When a higher bill can be correct
Most doctors “accept assignment,” meaning they take Medicare's approved amount as full payment. Some don't. They can charge up to 15% more than the Medicare-approved amount (the “limiting charge”), and the MSN's maximum already includes that.
A bill can also be higher for things that aren't on the MSN: services Medicare doesn't cover (most dental care, hearing aids and routine eye exams, for example), or a service your parent agreed in writing to pay for when they signed an Advance Beneficiary Notice. A provider who has opted out of Medicare and had your parent sign a private contract won't appear on the MSN either.
What to say when you call billing
- Have the bill, the matching MSN page, and your parent's Medicare card ready. You'll need your parent's permission to discuss the account.
- Say: “The Medicare Summary Notice for [date] shows the maximum she may be billed is $[amount]. Your bill is for $[amount]. Can you check that Medicare's payment and adjustment were applied?”
- Ask them to put the account on hold while they check, so it isn't sent to collections.
- Ask for a corrected, itemized statement. Write down the date, the person's name and a reference number.
If the provider won't fix it
Call 1-800-MEDICARE (1-800-633-4227) with the MSN in front of you and explain that the provider is billing more than the maximum. If you think your parent is being billed for something they never received, you can also contact your Senior Medicare Patrol (smpresource.org).
If your parent has a Medicare Advantage plan, the same idea applies to the plan's Explanation of Benefits: compare the bill with “what you may owe,” then call the plan's member services number if the provider won't correct it.
Common questions
- What does “maximum you may be billed” mean on a Medicare Summary Notice?
- It's the most the provider can bill your parent for that service after Medicare's payment, including deductibles and coinsurance. Other insurance like Medigap or Medicaid may pay some or all of it.
- Should we pay a bill that's higher than the maximum?
- Not until you've called the provider's billing office. Bills are often sent before Medicare's payment is applied, and a corrected one follows.
- Can a doctor charge more than the Medicare-approved amount?
- A doctor who doesn't accept assignment can charge up to 15% more (the limiting charge). The MSN's maximum already includes that, so a bill above the maximum still needs checking.