When not to show patient paid amounts on claims

First Coast was contacted by our 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 (or the electronic equivalent). 

Here are a few notes concerning this situation:

• When assignment is accepted:
  • No Part B payment is made on a claim to anyone other than the physician or supplier, even if the beneficiary has paid part of the bill. However, if the physician or supplier collects any charges from the beneficiary before submitting the claim, he/she must show on the claim form the amount collected in item 29 of the CMS-1500 (02/12) claim form (or the electronic equivalent). First Coast refunds the beneficiary, to the extent feasible, any over-collection of deductible and coinsurance. The physician is responsible for refunding to the beneficiary any over-collection not refunded by First Coast directly.
    • It is the provider's obligation to refund any over-collections to the beneficiary. Also, the beneficiary will be informed on their remittance advice of the amount of any refund due from the provider.
  • 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 in item 29 of the CMS-1500 (02/12) claim form (or the electronic equivalent). 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. 

Reference

• CMS IOM Pub. 100-04 Chapter 1, section 30.3.1.1 and 30.3.3.B
• Chapter 26, section 10.4