Miscellaneous Services and Charges - JE Part A

Providers are not allowed to charge a patient for filing a claim appeal.

Providers may send a beneficiary to a collection agency to recover valid patient responsibility amounts. A provider cannot recover the cost of the collection agency by charging the patient additional fees.

Providers are not allowed to bill or collect funds, for any reason, from a patient for a claim that has denied as contractual obligation (CO).

Participating providers agree to accept the Medicare Physician Fee Schedule (MPFS) amounts as "the full charge for the service," therefore; they may not collect more than the applicable deductible or coinsurance amount from the Medicare beneficiary.

Charging a patient to be "on call" or a retainer to coordinate care with other providers, a comprehensive assessment and plan for optimum health or extra time spent on patient care is considered to be in excess of the amount allowed to charge for a Medicare service. The special services for added payment are known by various names and may include "boutique medicine," "retainer practice," or "platinum practice." The Office of the Inspector General (OIG) has specifically addressed this topic.

If a patient requests a copy of their medical documentation, the amount to charge the patient for the cost of creating the copy is at the discretion of the provider's office. Fees for documentation requested from the provider by Noridian are not billable either.

Noridian knows of no Medicare regulation requiring providers to employ or provide a foreign language interpreter for patients, however, the issue may be addressed at the state level. There is no Medicare benefit for foreign interpreter services.

Providers may reduce or eliminate the amount a patient owes after Medicare has paid if:

• Providers offer the same benefit to ALL of their patients
• Providers have a documented process of qualification requirements and guidelines

Participating providers agree to accept the MPFS amounts as "the full charge for the service," therefore; they may not collect more than the applicable deductible or coinsurance amount from the Medicare beneficiary.

Non-participating providers may not collect more than the limiting charge. The application of interest would be a violation of a provider's participation agreement with Medicare or lead to an impermissible increase to the limiting charge.

State laws generally govern how long medical records are to be retained. However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 administrative simplification rules require a covered entity, such as a physician billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. HIPAA requirements preempt State laws if they require shorter periods. Your State may require a longer retention period. The HIPAA requirements are available at 45 CFR 164.316(b)(2).

Medicare law and regulations do not prevent an entity that sees Medicare beneficiaries from charging a Medicare patient for a missed appointment, if it concurs with an internal policy that is applicable to ALL patients who receive services from that entity. The policy should comprise the same fee for all patients. See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.3.13

If claims have denied as CO, providers are not allowed to bill beneficiaries that are not responding to requests for information. The below examples are not all inclusive.

• Patient does not return calls or correspondence
• Patient has not provided information about insurance that is primary to Medicare or HMO coverage
• Provider has an incorrect or invalid Medicare number

These providers are NOT subject to any of the above guidelines and cannot bill Medicare. They have private contracts with their patients that dictate the terms in the patient/provider relationship.

Providers must refund a patient, within a reasonable timeframe, if the patient has overpaid the provider unless an appeal of the claim has been requested. See CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.12.1

Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), also known as the physician self-referral law and commonly referred to as the "Stark Law"

View exceptions to "foreign" exclusion

Medicare regulations do not provide payment under Part A or Part B of Medicare for expenses that constitute charges by immediate relatives of the beneficiary or by members of his/her household.

Noridian knows of no Medicare regulation requiring providers to employ or provide a sign language interpreter for patients, however, the issue may be addressed at the state level. There is no Medicare benefit for sign language interpreter services.

A provider may not bill a non-Medicare patient a lesser fee than a Medicare patient according to 1128(b)(6) of the Social Security Act. If you have a fee schedule for your privately insured patients and another for your Medicare patients, the MPFS could be lower than the privately insured fee schedule, but not higher.

However, it is appropriate to have another fee schedule for the uninsured that is lower than both the private and the MPFS; this is acceptable because it applies to a specific type of patient, the uninsured. A provider should have a clear definition of how and when each fee schedule is applied.

There is not a Medicare benefit for providers for employing any type of special service staff, i.e., staff not licensed to perform medical services. They are considered to be an employment cost incurred by the provider and part of the payment of Medicare claims under "incident to" guidelines.

Participating providers: When admitting or registering patients, the provider must determine whether beneficiaries have medical insurance coverage, which can be done through the Noridian Medicare Portal. Instructions on how to check eligibility in the portal can be found on our Inquiry Guide page. At that time, the provider may collect deductible, or coinsurance amounts only where it appears that the patient will owe deductible or coinsurance, and where it is routine and customary policy to request similar prepayment from non-Medicare patients. If the beneficiary can show his/her deductible status and the Part B deductible is met, the provider will not request or require prepayment of the deductible.

Note: Not all services may have cost-sharing amounts.

Non-participating providers: For non-assigned claims, the provider can collect the allowed amounts upfront.