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Last Modified: 5/9/2019 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. and 30.3.3.B external pdf file; Ch 26, Sec 10.4 external pdf file
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.