# Billing Medicare, then changing to self pay so the patient pays less



## Wendy McBride (Aug 8, 2014)

Good morning all! 

I am trying to find official rules & regs regarding a potentially sticky problem:

If we have billed Medicare for a service, and it is a non-covered charge per Medicare's EOB, Is it legally and ethically alright to give the patient the private-pay (cash) price to give them "a break on cost"..?

I cannot find anything definitive either way, but it just doesn't seem like sound billing practice... Any assistance, preferably with article references, would be greatly appreciated...


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## Pat Liebl (Aug 8, 2014)

If Medicare says it not covered you cannot bill the patient unless they signed a waiver


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## mitchellde (Aug 8, 2014)

Since you are not suppose to have a separate fee schedule for private pay for this very reason the answer is no. The EOB from Medicare tells you exactly what you are to charge the patient.  If you charge the patient less than you would charge Medicare then Medicare will have a huge issue with that. For one it violates the false claim statute among others.


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## jromeyn (Aug 8, 2014)

You can not charge a patient a self pay rate or give a discount if you are contracted with their insurance. 
Also if Medicare says they won't pay for it, you can't charge the patient at all unless they signed an ABN.


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## Wendy McBride (Aug 8, 2014)

I thank all of you for your assistance... I do have a clarification:

This patient's charge was applied to the Medicare deductibe. The provider would Medicare to be told the service did not happen, and give the patient a discounted rate.

Can anyone give me chapter and verse showing the illegality/fraudulence of this?


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## mitchellde (Aug 8, 2014)

You cannot do this as your fee communicated to Medicare cannot be more than the fee you charge the patient.  You can research this under false claims, or HIPAA, Medicare appropriately applied the charge to the deductible, you must charge the patient what Medicare says they owe.  You cannot now act like the service never took place.  HIPAA states that by knowing you are to charge a certain rate, but electing to charge a lower rate constitutes an act of fraud.


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## Wendy McBride (Aug 8, 2014)

Thank you Debra! As ever, you are a wonderful fountain of knowledge!


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## christinaob (Mar 6, 2019)

mitchellde said:


> You cannot do this as your fee communicated to Medicare cannot be more than the fee you charge the patient.  You can research this under false claims, or HIPAA, Medicare appropriately applied the charge to the deductible, you must charge the patient what Medicare says they owe.  You cannot now act like the service never took place.  HIPAA states that by knowing you are to charge a certain rate, but electing to charge a lower rate constitutes an act of fraud.




I would also explain to the patient and/or the physician that you are causing more harm than good as the patient is going to have to pay the $185 Deductible each year so if you were not charging Medicare for the visit (and billed him selfpay) then the next persons claim would apply to the deductible.  Now the patient has to pay your selfpay claim and still the $185 - how did that help the patient.


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