Last Modified: 1/16/2018 Location: FL, PR, USVI Business: Part B
When not to show patient paid amounts on claims
First Coast Service Options was contacted by our Centers for Medicare & Medicaid Services (CMS) regional field office regarding beneficiary complaints of being charged up front in the office for services rendered and the money was collected prior to a claim being submitted to Medicare.
Although it's not a violation for participating providers to accept payment prior to rendering services, there are specific guidelines to follow, especially when reporting these payments.
Additionally, some providers who accept assignment have a concern that Medicare issues partial checks to beneficiaries. Such checks are generally issued because of a patient paid amount in item 29 of the CMS-1500 (02/12) claim form.
Here are a few notes concerning this situation:
• When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable (and over-collection is considered program abuse), it is recommended that providers do not collect these amounts until Medicare Part B payment is received.
• If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. It is recommended that providers do not collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse. In addition, this practice can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.
• Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.
• There is no need to show a patient paid amount in item 29 of form CMS-1500 (or electronic equivalent) when assignment is not accepted.
Source: The Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Pub. 100-04 Ch. 1, sec. 18.104.22.168 and 30.3.3.B ; Ch 26, Sec 10.4
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