Medicare Compliance & Reimbursement

Question: We have a patient who wants us to directly bill her allowable charges for a procedure so that she can pay our office this amount instead of paying her deductible since she has a very high deductible. Is this legal?

Answer: If your provider has a contract with the insurance company, you must submit the claim to the payer and then collect from the patient only the amount indicated by the explanation of benefits (EOB).

Pitfall: If you do not submit the claim, there is nothing to prevent the patient from submitting the claim and being reimbursed, and the practice then being accused of noncompliance with the payer-physician contract.

Additionally, without submitting a claim with all of the charges, you cannot ever be sure of the "allowable amounts." Even with a payer’s fee schedule available to the physician, each patient may have a different plan, with each plan paying different amounts and with different deductibles. Without a claim and resultant EOB, your practice will not know that particular patient’s allowable fees.

Don’t forget: If your practice does not participate with the plan, you should not be reducing the fees to "allowable amounts" since the practice’s fee schedule is allowable in any non-participating situation.