Medicare Compliance & Reimbursement

Myth #1: You have to bill everyone the same amount.

Fact: "Practices cannot bill Medicare patients higher than other payers," says Suzan Berman-Hvizdash, CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology in Pittsburgh. "However, if they have a contractual agreement with another payer to charge that payer more, they can do so," she says.

Practices often maintain several fee schedules that correspond to different insurers. "The most important piece is the reimbursement," Berman-Hvizdash says. "The contracts with the various payers are going to dictate the reimbursement. This could vary greatly from payer to payer, state to state, contract to contract."

Myth: If Medicare doesn't pay the full charge for a service, you are obligated to write off the rest.

Fact: If you participate in the Medicare program, you can bill the patient for the co-insurance amounts and the deductible (if it comes out of your claims), Berman-Hvizdash says.

Example: You billed $350 for an office visit. The Medicare fee schedule amount is $100. Patient has $15 left to his deductible. The break down would look like this:

Medicare allows: $100

Medicare pays: $65

Deductible: $15

Co-insurance: $20

Patient owes: $35 (Co-insurance plus remaining deductible)

Physician Write off: $250.