• Industry News
  • Access and Reimbursement
  • Law & Malpractice
  • Coding & Documentation
  • Practice Management
  • Finance
  • Technology
  • Patient Engagement & Communications
  • Billing & Collections
  • Staffing & Salary

Unique fee schedule for Medicare/Medicaid

Article

Is it legal for a practice to charge Medicare/Medicaid according to one fee schedule and to charge commercial carriers at another fee schedule? My office would have two fee schedules. The reason is that the allowable from CMS and some of the commercials are so varied, especially for surgery, that the practice is concerned that Medicare/Medicaid may see it as overcharging CMS. I am aware the OIG is unsuccessfully pushing for Medicare charges to exceed no more than 120 percent of the allowable amount. In this scenario self-pay patients would be charged a fee equal to the Medicare allowable or up to the limiting charge (115 percent) of the Medicare allowable depending on practice.

Question: Is it legal for a practice to charge Medicare/Medicaid according to one fee schedule and to charge commercial carriers at another fee schedule?

My office would have two fee schedules. The reason is that the allowable from CMS and some of the commercials are so varied, especially for surgery, that the practice is concerned that Medicare/Medicaid may see it as overcharging CMS. I am aware the OIG is unsuccessfully pushing for Medicare charges to exceed no more than 120 percent of the allowable amount. In this scenario self-pay patients would be charged a fee equal to the Medicare allowable or up to the limiting charge (115 percent) of the Medicare allowable depending on practice.

Answer: There is no legal reason not to charge Medicare/Medicaid more than they pay. It is your usual and customary charge. Furthermore, you run the risk of commercial payers insisting that what you charge Medicare/Medicaid is your usual and customary charge, and they’ll happily pay you the same.

Plus, you run the risk of making mistakes and charging wrong. And, your gross collection rate will be whacked out. Why try to solve a problem that does not exist? There are enough problems that do exist.

Related Videos
Physicians Practice | © MJH LifeSciences
The importance of vaccination
The fear of inflation and recession
Protecting your practice
Protecting your home, business while on vacation
Protecting your assets during the 100 deadly days
Payment issues on the horizon
The future of Medicare payments
MGMA comments on automation of prior authorizations
The burden of prior authorizations
Related Content
© 2024 MJH Life Sciences

All rights reserved.