Private Payments from Medicare Beneficiares

[pvtbiller]

Good Afternoon everyone.  My question may seem simple but dealing with Medicare - I am sure it is complex.  We were just informed that the first generation of our product was assigned the A9270 code (non-covered).  Even though we now have the 2nd generation with added benefits - Medicare is still denying coverage.  We are having better luck with the private payers (sometimes) reimbursing but it seems that Medicare (traditional) is our biggest demographic market).  If I issue an ABN (which i believe is voluntary), would I still have to charge the patient (cash-upfront) what I bill Medicare?  Also, for private pay patients, can I offer them a discount or do I have to charge them the retail price as well so that we are not in any type of hot water with Medicare?  I also wanted to mention that we are non-par with traditional medicare.  Thank you all for your expertise and knowledge!

[RichardP]

... we are non-par with traditional medicare. ... If I issue an ABN

Effective 9-12 - Providers and suppliers who are not enrolled in Medicare cannot issue the ABN to beneficiaries.

From here, at Section 50.3 on Page 12 (1st Paragrah);  see also Section 50.3.2 on Page 13; see also Section 50.1 on Page 10.

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/downloads/RevABNManualInstructions.pdf

... would I still have to charge the patient (cash-upfront) what I bill Medicare?

The charge you give to a patient should always match the charge you place on the Insurance Form you send to the insurance carrier, regardless of whether it is Medicare or private.

... for private pay patients, can I offer them a discount ...

Yes.

Price discrimination by physicians and hospitals is legal.  The Robinson–Patman Act of 1936, an amendment to the Clayton Antitrust Act, prohibits price discrimination - but only for commodities.  It does not prohibit price discrimination for services.  And hospitals and insurance companies and doctors do engage in price discrimination - all quite legally.   Doctors and hospitals are free to discriminate in the pricing of their services, except where contrained by state and Federal regulations, and by their contracts with the insurance carriers.  For a doctor who is seeing cash patients, as in your example, the constraints are (almost?) non-existant (I phrase it that way, because I do not know the regulations in every state).  That is, for a non-medicare cash patients, the doctor can legally charge each patient a different price.

For those interested in more information, Google on "price discrimination" + healthcare (or 'doctors').

From my comments at this thread:

http://www.medicalbillinglive.com/members/index.php?topic=7116.0

[pvtbiller]

Thank you Richard.  I did want to clarify that we are enrolled with Medicare but as a nonparticipating supplier.  So would your response still hold true?  Also, we do offer a commodity (DME Equipment for purchase) and not such a "service" like a physician visit so could I still charge a patient what ever I wanted under the act?

[Billergirlnyc]

I did want to clarify that we are enrolled with Medicare but as a nonparticipating supplier.  So would your response still hold true?  Also, we do offer a commodity (DME Equipment for purchase) and not such a "service" like a physician visit so could I still charge a patient what ever I wanted under the act?

I gathered from your original question that your doctor was "non-par" with Medicare, which isn't the same as not enrolled/credentialed. I think a lot of people confuse the two.

If the provider is non-par with Medicare see the link at the end of this comment. The link was recently revised with new info last month. It will help you better understand how non-par Medicare providers can bill Medicare patients and how much. When a provider doesn't sign the PAR agreement with Medicare it doesn't absolve them from following Medicare's guidelines for non-par providers. Click Here.

I use to have a provider who was non-par and he didn't know there was a difference between assigned and unassigned with non-pars and that he was allowed to do both on a case by case basis. Again the aforementioned link will help you and your provider understand how it works. ABN's still come into play for non-par Medicare providers so I would use them for any service that you know is considered "non-covered" by Medicare. Look at Medicare's LCD's for the modalities you bill for. You can search by code, etc. You can't have patients sign blanket (meaning the codes need to be written in at the time of service) ABN's thus why I'm suggesting you get the LCD. Here is a link to a pdf by the AMA that I give to my providers so they can FULLY understand the 3 different types of providers they can be with Medicare and the expectations of all of them. AMA PDF. The AMA even has a handy calculator AMA MC Calculator.

So, yes, I would get ABN's from all Medicare patient's for this code you're billing, but remember you're not suppose go BACK and get them, they're suppose to be done at the time of service and the patient doesn't have to pay if you didn't make them sign it beforehand (you can confirm this by calling Medicare or searching their guidelines on ABN's). If patients are forced to pay then they can file an appeal with Medicare to prove why they don't have to, just like they can appeal a denial — just an FYI.  Also remember you'll need to determine if the doctor accepts (or accepted) assignment or not for these patients to determine what can and can't be billed to the Medicare patient. All this matters and again all is discussed in 2 of the links I provided. 

EDITED: Links weren't working, corrected.

[RichardP]

Billergirlnyc - could you please put a space between the last letter and the period in the last two links you provided.  They way they are currently set up, the period becomes part of the URL, and therefore does not work.

pvtbiller said:  ... we are enrolled with Medicare but as a nonparticipating supplier ...  Thanks for the clarification.

Billergirlnyc said:  "non-par" with Medicare, which isn't the same as not enrolled/credentialed. I think a lot of people confuse the two.  Exactly.  I didn't want to assume what you meant in your first post.  Rather than waiting for your response to a request for clarification, I posted the comment about providers not enrolled with Medicare, which is a new addition to the CMS Instructions.

Based on your response, I was going to post the following link, but Billergirlnyc beat me to it (this is a repeat of the first link Billergirlnyc gave).

http://www.aafp.org/online/en/home/practicemgt/mcareoptions.html

In the link it discusses the three states that providers can have with Medicare:

 - Participating (enrolled with Medicare; must give ABNs where necessary)
 - Non-Participating (enrolled with Medicare; may or may not give ABNs)
 - Private Contracting (may not give ABNs)

pvtbiller said:  ... we do offer a commodity (DME Equipment for purchase) and not such a "service" like a physician visit so could I still charge a patient what ever I wanted under the act?

No.  If you choose not to participate in the Medicare program and do not accept assignment on your claims, the maximum amount you may charge is 115 percent of the approved fee schedule amount for non-participating providers.  Remember that, whatever you charge, the charge to the patient and the charge you submit to Medicare must be the same amount.  Read through the information about Non-Participation in the first link Billergirlnyc gave (and that I repeated above in this post), and the information under the heading If You Choose Not to Participate in this link:

http://www.cahabagba.com/part-b/enrollment-2/participating-vs-non-participating-part-b/

If you still have questions, come back.

[Billergirlnyc]

I just clicked on all my links and they work, perhaps you clicked on them before I edited earlier (see note at bottom of my post and time I last edited). Also can you utilize the "quote" button that your comments will be easier to read/follow. Thanks.

[RichardP]

Also can you utilize the "quote" button that your comments will be easier to read/follow. Thanks.

OK.

Your last two links didn't work for me at the time I posted, but they work now  Thanks.