Reminder on mandatory Medicare claim submission requirements

The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries. The requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment. 

Compliance to mandatory claim filing

Compliance to mandatory claim filing requirements is monitored by the CMS. Violations of the requirement may be subject to:

• A civil monetary penalty of up to $2,000 for each violation;
• A 10% reduction of a physician’s / supplier’s payment once the physician / supplier is eventually brought back into compliance; and/or
• Medicare program exclusion.

Medicare beneficiaries may not be charged for preparing or filing a Medicare claim. 

Exceptions to mandatory claim filing

Physicians and suppliers are not required to file claims on behalf of Medicare beneficiaries for: 

• Used durable medical equipment purchased from a private source;
• Medicare secondary payer claims when the providers do not possess all the information necessary to file a claim;
• Foreign claims (except in certain limited situations);
• Services furnished by opt-out physicians or practitioners (except in emergency or urgent care situations when the opt-out physician or practitioner has not previously entered into a private contract with the beneficiary);
• Services that are furnished for free; or
• Services paid under the indirect payment procedure.

Please make sure you review the requirements with your staff to ensure compliance with the mandatory claim filing requirements. 

References

• SSA Section 1848(g)(4)
• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, section 70.8.8