# self pay for Medicare patient



## abranch13

I have a Medicare patient who has Medicare secondary and absolutely does not want us to use his Medicare at all, does not want us to file claims to them.  We are Medicare participating providers so I was not sure if this is even an option, can we bill his primary commercial insurance and then balance bill the patient?  If so, do we need to get something in writing from the patient to document this agreement?

Thanks


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## cczech

Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

Here's what happens if your doctor, provider, or supplier accepts assignment:

Your out-of-pocket costs may be less.
They agree to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share.
They have to submit your claim directly to Medicare and can't charge you for submitting the claim.

If you accept assignment from Medicare you have to bill them. The only way you don't have to is if it is something Medicare would not cover then you could have the patient fill out an ABN- Advanced Beneficiary notice and then you could bill the patient.


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## capricew

I have to disagree with the above comment.  If a patient does not want medicare billed- i think you could get away with the patient signing a waiver that he wishes not to have medicare billed.  I do not think you will get "in trouble" for not billing Medicare.  
If I am wrong, please guide me to where it states that a contracted provider must bill medicare.  

Sincerely,

Caprice Walder, CPC


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## OCD_coder

The Social Security Act states that participating providers must bill Medicare for covered services.  The only time a participating-provider can accept "self-payments" is for a non-covered service.  For Non-participating providers, the patient can pay and be charged up to 115% of the Medicare Fee Schedule. 

Whether the provider is a Medicare Participating or Non-Participating Provider and they are going to provide services to a MC beneficiary that are not considered “Medically Necessary” or go beyond a therapy cap, then it is mandatory to provide the patient with an ABN before further treatment is provided.  The patient can elect whether Medicare is sent a claim via the ABN form, #2.  The patient will be reimbursed directly from Medicare, not the provider.


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## MarcusM

The other thing to consider is many commercial insurance plans that are primary to Medicare do periodic cross checks (COB) and when they find Medicare is secondary, the claim is auto adjudicated and sent electronically to Medicare with the primary's remittance report.


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## Spring2Code

When physicians had to update their HIPPA policies and procedures to comply with HIPPA Omnibus rule back in September it had a section on patient rights under disclosures to health plans. It states "physicians and other health care providers to abide by a patient's request not to disclose PHI to a health plan for those services for which the patient has paid out-of-pocket and requests the restriction."  I understood this new HIPPA Privacy Rule to let patients pay if they wanted out of pocket and not bill insurance. 

Spring Morelli, CPC


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## drwsrapidfire@yahoo.com

Hello, just to be clear, if a provider accepts Medicare, they have to bill Medicare for the service ? If a patient wants to pay for the visit and have it NOT sent to Medicare Insurance., is that permitted by Medicare?
Thank you for any help/
Ruthnane Wickware, COPC


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## csperoni

drwsrapidfire@yahoo.com said:


> Hello, just to be clear, if a provider accepts Medicare, they have to bill Medicare for the service ? If a patient wants to pay for the visit and have it NOT sent to Medicare Insurance., is that permitted by Medicare?
> Thank you for any help/
> Ruthnane Wickware, COPC


Yes, for any insurance, a patient may decide they want to pay for the visit and NOT have the claim sent to the insurance.  I would suggest having the patient sign something that states they are choosing to pay on their own.


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## SharonCollachi

csperoni said:


> Yes, for any insurance, a patient may decide they want to pay for the visit and NOT have the claim sent to the insurance.  I would suggest having the patient sign something that states they are choosing to pay on their own.


There are, however, specific guidelines for Medicare and the HITECH act:  

_HITECH requires that any HIPAA covered entity offer a cash price to patients desiring to keep their protected health information private from their "health plan."  This election is available to Medicare patients, though the Medicare limiting rates still apply when the patient pays the practice out of pocket in full.  The physician is free to offer a rate less than the Medicare amount to any patient including Medicare patients.  A detailed explanation is included in the Federal Register from pages 5,623 to 5,634.  Here is another helpful resource from MGMA._

See more here:  https://www.dpcfrontier.com/hitech


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## csperoni

Good info Sharon!  I was unaware of the limiting rate if a patient is choosing to pay for the service.  Of course, I can't recall the last time I had any patient requesting to pay even though they have health insurance.  It's never happened at my current position of 16+ years in gynecologic oncology, but did occur maybe 3-4 times in 10 years when I worked in primary care.


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## drwsrapidfire@yahoo.com

SharonCollachi said:


> There are, however, specific guidelines for Medicare and the HITECH act:
> 
> _HITECH requires that any HIPAA covered entity offer a cash price to patients desiring to keep their protected health information private from their "health plan."  This election is available to Medicare patients, though the Medicare limiting rates still apply when the patient pays the practice out of pocket in full.  The physician is free to offer a rate less than the Medicare amount to any patient including Medicare patients.  A detailed explanation is included in the Federal Register from pages 5,623 to 5,634.  Here is another helpful resource from MGMA._
> 
> See more here:  https://www.dpcfrontier.com/hitech


Thank you Sharon, very good information.


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