# Billing Medicare a lower fee



## klobo (Sep 12, 2013)

Hello,
I have a client who wants to charge a total of  $35 for self-pay patients for  the following vaccine:

Pneumovax 90732 - Medicare pays $73.35
Vaccine inj 90471 (G0009 for Medicare) - Medicare pays $24.06

The client wants to bill Medicare $75 for 90732 and $25.00 for 90471 - a total of $100.00

Is it legal to bill Medicare a higher fee than what you offer to your other patients?
Or do we have to bill Medicare the lowest fee offered to the patients?

Any advice on this issue would be appreicated,

Thx a lot,
ken


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## orazzals (Sep 12, 2013)

The places I have worked at usually have two fee schedules, Medicare and all other carriers which is a certain % higher than Medicare. Medicare pays what Medicare pays. If they usually pay $100 for something and you only charge them $80 they are going to pay you $80. Don't short change yourself. 
I am not sure about the legal aspect of charging a lower fee to self pay than the insurance companies. You might want to ask a lawyer that specializes in Medical cases.


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## annawade13 (Sep 13, 2013)

klobo said:


> Hello,
> I have a client who wants to charge a total of  $35 for self-pay patients for  the following vaccine:
> 
> Pneumovax 90732 - Medicare pays $73.35
> ...



It is absolutely not allowed to charge private pay patients a lower price than is charged to Medicare. Only one fee schedule is allowed. Our compliance officer says the way to get full reimbursement from Medicare and still make services affordable to uninsured patients is to offer a hardship discount. The pt must "prove" hardship (which can be as simple as a signed statement saying paying full price would be a financial hardship that may lead to them not seeking needed medical services) and then the price can be dropped to a pre-determined "hardship price." It works out the same, but if Medicare audits you, they'll see that all the 90732s in your system have the same price.

Alternatively, our back up policy for uninsured patients if no hardship form was signed is to show good faith attempt to collect (we define this as two statements), and then write off as "bad debt."

The Office of the Inspector General website https://oig.hhs.gov/ has a lot of good information about this.

Hope this helps!


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