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PMRNC:
--- Quote ---"Some practices charge for procedures based on the Medicare-allowable amount, automatically write off the difference between what they normally charge for the procedure and the Medicare allowable, and bill Medicare the allowable. Then, when Medicare pays its 80 percent of the allowable, the practice can easily determine and record in its billing computer system the 20 percent owed by the patient. Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law.
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I think you misunderstood it.. IT states that practices DO THAT TO AVOID.... In other words, practices that are billing the allowable ARE most likely DOING SO TO AVOID billing patient's more than their 20 percent. It's merely a reason as to why providers would do it. It is absolutely a violation of Medicare law.
--- Quote ---Not that I'm arguing the common sense of it... I just don't think it's "illegal". Yes, it may raise red flags, yes, it may get you audited, yes, it may get you in trouble with other insurances, but not "illegal"
JMO
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It states it IS a violation of Medicare Law.. that means "illegal"
dekenn:
Anyone else have a take on this?
I still stand by my original interpretation. "Practices do this to avoid...." means that instead of making sure they take the appropriate adjustment, they bill the allowable so they don't have to worry about it. And, I still say that the phrase "which is a violation of Medicare law" modifies "billing patients more than their 20 percent of the allowable."
I think it's stating that "practices do this" as an informative statement, going on to explain that it's a shortcut of sorts to avoid billing the patient more than 20 percent. If they bill the Medicare allowable, and that is the amount in their system, when Medicare pays their 80%, the only thing left is the 20%, no adjustments need to be made, etc.
Michele:
Actually I did some research on this several years ago (I'll avoid the long story as to why!) and I was informed by Medicare that it is illegal for providers not to attempt to collect the 20% balance. They don't have to collect it, but they have to attempt to collect it. It is illegal for a provider to just write off the 20% patient responsibility without attempting to collect. Then they are supposed to document their efforts.
OK, I'll explain a little. We were researching for a non-profit local ambulance company. They wanted to raise revenue by billing insurance but they did not want to collect any monies from patients, since they were a very rural, non-profit, basically free ambulance service. If I remember correctly they were volunteers. Anyway, most patients are Medicare so they wanted to know if they could bill Medicare, but not charge the patient for any balance. The answer was a resounding 'NO'. But then it was further explained that they needed to ATTEMPT to collect the balance and document those attempts.
Michele
dekenn:
I don't think the issue was not billing the patient the 20%, I think it was the amount that actually goes on the claim to Medicare. If a provider puts the Medicare allowable on the claim, Medicare will then pay it's 80% share, leaving 20% patient balance. This whole amount can then be billed to the patient without worrying about whether it's the correct amount or not.... after Medicare pays, the only thing left is the 20%.
For example, if a provider charge for 99213 is normally $100. Assume Medicare allows $80.00, pays $64.00 with a $16.00 patient balance. The provider now has to make sure the system is set up to make the medicare adjustment of $20.00 to avoid billing it to the patient. On the other hand, if the provider puts $80.00 on the claim, gets paid the $64.00, the only thing left is the $16.00 patient balance..... no adjustments have to be made.
The downside of this is if you don't update your fees according to the Medicare allowable, you could be billing Medicare LESS than their allowable (yes, occasionally, the reimbursements do go UP!! ;) )
PMRNC:
--- Quote ---I don't think the issue was not billing the patient the 20%, I think it was the amount that actually goes on the claim to Medicare. If a provider puts the Medicare allowable on the claim, Medicare will then pay it's 80% share, leaving 20% patient balance. This whole amount can then be billed to the patient without worrying about whether it's the correct amount or not.... after Medicare pays, the only thing left is the 20%.
For example, if a provider charge for 99213 is normally $100. Assume Medicare allows $80.00, pays $64.00 with a $16.00 patient balance. The provider now has to make sure the system is set up to make the medicare adjustment of $20.00 to avoid billing it to the patient
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What Michele was saying was that by billing the "allowable" Medicare CAN and DOES interpret that to mean the coinsurance is being waived (remember, if it's not documented it's not done, not just in the coding world. Medicare assumes providers are charging what they would charge any other patient. Medicare pays their portion (%) OF the allowable, by lowering the allowable on your CMS1500 Medicare CAN interpret that to be that the provider has waived the coinsurance.
AT every medicare seminar I've ever attended this comes up.. all the time and the answer is the same. NO. how Michele explained it is how Medicare interprets it. But like I said, I don't argue this with anyone, I just won't bill it like that. As my attorney always reminds me, worry about your own ass.
--- Quote ---I still stand by my original interpretation. "Practices do this to avoid...."
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I still think you are not reading the rest of the sentence which is the most important part, also the law is the law, it's not up for us to interpret it unless we want to end up in a court room paying an attorney. The rest of that sentence IS the bulk of it and is very clearly stated:
--- Quote ---"Some practices charge for procedures based on the Medicare-allowable amount, automatically write off the difference between what they normally charge for the procedure and the Medicare allowable, and bill Medicare the allowable. Then, when Medicare pays its 80 percent of the allowable, the practice can easily determine and record in its billing computer system the 20 percent owed by the patient. Practices do this to avoid billing patients more than their 20 percent of the allowable, which is a violation of Medicare law.[/u]
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Practices do this to avoid billing patients more than their 20% of the allowable, WHICH....... is a violation of Medicare Law.
Now maybe the practice still intends to bill the coinsurance you will say? That's MOOT because MEDICARE has stated they will interpret the billing practice as illegal.
This is actually stated from my fathers Medicare booklet,on an insert on how beneficiaries can avoid fraud/abuse. I pulled it out of there because it was easier to understand than the legal mumbo jumbo so that Medicare Beneficiaries can be on the look out for fraud and/or abuse by their providers.
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