You can't bill a Medicare patient for more than what's allowed by Medicare. If the item you mention is 340.00 and Medicare's allowable is 300 and they pay 240, the clients coins is the 60. If the 2ndary doesn't pay because it is over their allowables, then the patient can be billed for his coins. I don't know what upgrade you are speaking of except in DME where Medicare only covers a certain item but the client after signing an ABN can receive the upgraded (wheelchair/bed etc) and pay the difference. WE however have to bill Medicare for the Upgraded item, but they will downcode, and thus we can bill the patient.