Medicare Charges

[dfranklin]

Does Medicare limit on what we can charge? I know they have limits on what we can pay but is there a limit on what we can charge or do we just charge what ever fees the provider feels is standard to all insurances and medicare reduces as necessary?  My provider thinks we can't charge over a certain limit to medicare....

Thanks!

Don

[PMRNC]

Yes, it's called the "Limiting Charge" It is on the EOB, doctors can charge 15% above allowable.

[dfranklin]

So then you have to have 2 sets of fees loaded into your software. 1 for Medicare where it is only 15% above allowable and the other set for all other carriers? 

What happens if you charge above the limiting charge or 15%?

[Pay_My_Claims]

HUH?? You only have 1 fee schedule

[Michele]

I'm assuming this is a non par medicare provider.  You can bill your regular fees to Medicare but you can only charge the patient what Medicare says you can.  If it is a non par provider, they can charge the patient up to the limiting fee.

Michele

[dfranklin]

I am confused too...if we can't bill medicare more then 115% of allowable then how do we bill Medicare vs other carriers?  EXAMPLE: Lets say service XYZ has a medicare allowable of $100 which means we can file a claim to medicare for $115.  But the doctor actually charges $150.  So for all other carriers the claim is to be filed for $150.  Isn't that 2 different fee schedules because the provider is not able to charge his usual and customary to medicare because it is over the 115% limiting charge?


Or does that limiting charge apply to non-assignment accepting providers so that you can not bill the patient over the 115%? Meaning allowable is $100, provider's usualy & customer is $150 but we can only bill $115 so that the patient is not billed more then we are allowed?

As you can see I am confused with what we can bill to Medicare etc.  Please help!  Thanks!!!

[dfranklin]

So michelle if we are accepting assignment then we of course are going to adjust according to the EOB so we would be balance billing according to what Medicare allows correct? 

And even if we were not accepting assignment the EOB will show what is over the limiting charge and we would need to adjust that off so that we don't balance bill the patient over the 115%, correct?

Thanks for your help!!!

[Michele]

You can BILL Medicare whatever you want, it's what you do after Medicare makes payment that is crucial.

If you are a participating provider, you cannot bill the patient any higher than the allowed amount.

If you are a non participating provider, you cannot bill the patient any higher than the limiting fee, which is 115%.

You can BILL Medicare your regular fees, the same as you bill the other commercial carriers, but you must write off anything over the allowed amount once the claim is processed.

Hope that clears it up.

Michele

[dfranklin]

It does...Thank you Very much!!!

[sagemb]

not that there is any need, but I would like to 2nd what Michele just said.

We're billing colonoscopy for $1000.00. Some types are even billed at $1100.00.
Medicare allowable is close to 25% of this amount. But it never stopped us or that medicare ever gave us a hassle about it.

Just as long as medicare pay's it's full allowable, or pays partial allowable and we can then billing the remaining allowable balance off to patient or 2nd carrier, whatever the case maybe.