Wiki Medicare Limiting Charge Amount

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baskiles

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Local Chapter Officer
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EOB states patient has opted out of Medicare. EOB states that patient is responsible for payment but under Federal Law, we cannot charge the patient more than the limiting charge amount. Is the limiting charge amount Medicare's allowable? This was a matter that I did not completely understand when taking the CPB course. Any help or direction would be greatly appreciated.
 
The EOB states the patient or the provider has opted out? I don't think a patient can 'opt out' of Medicare.

In any case, the limiting charge is usually 15% above the Medicare allowable and is the maximum amount that a provider may charge a patient for a given service, and this is usually a cap that is applied when a provider files a claim to Medicare but does not accept assignment:


 
thomas7331 said:
The EOB states the patient or the provider has opted out? I don't think a patient can 'opt out' of Medicare.

In any case, the limiting charge is usually 15% above the Medicare allowable and is the maximum amount that a provider may charge a patient for a given service, and this is usually a cap that is applied when a provider files a claim to Medicare but does not accept assignment:


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Thank you for that information--- the payer is CIGNA- and we have confirmed that the 67 yo does not have Medicare and for that reason CIGNA is not paying the claim. CIGNA shows the Remark Code: MA56 "Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As a result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount."
Our provider accepts Medicare assignment. I'm wondering if CIGNA has adjudicated this clam incorrectly, maybe? Your thoughts?
 
It sounds to me like Cigna has either made an error or has given you incorrect information. The MA56 remark is addressed to the provider who has opted out of Medicare, not to the patient, and if your provider accepts Medicare assignment, then they are incorrectly stating that your provider has opted out of Medicare, which I gather from what you're saying is not true. The Medicare limiting charge applies to patients who DO have Medicare, not to ones who do not. Unless this is a Cigna Medicare replacement plan that your provider is not participating with? I would get on the phone with Cigna and get clarification from them of what is going on here and why they are stating that you are subject to a Medicare limiting charge if this is not a Medicare patient. Ask to speak with a supervisor if the representative can't give you a clear explanation for this.
 
thomas7331 said:
It sounds to me like Cigna has either made an error or has given you incorrect information. The MA56 remark is addressed to the provider who has opted out of Medicare, not to the patient, and if your provider accepts Medicare assignment, then they are incorrectly stating that your provider has opted out of Medicare, which I gather from what you're saying is not true. The Medicare limiting charge applies to patients who DO have Medicare, not to ones who do not. Unless this is a Cigna Medicare replacement plan that your provider is not participating with? I would get on the phone with Cigna and get clarification from them of what is going on here and why they are stating that you are subject to a Medicare limiting charge if this is not a Medicare patient. Ask to speak with a supervisor if the representative can't give you a clear explanation for this.
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Thank you very much. I will call CIGNA again.
 
I was also wondering if Cigna was secondary, or if it was a Medicare replacement plan (which doesn't make sense either, or how could the patient have it if they didn't have medicare??)
 
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