Re: Below cost reimbursement
Description
Collection
Title:
Re: Below cost reimbursement
Text:
I have been asked to post the replies to this question as well.
>> When Medicare reimbursement for a replacement item is below the cost of
the item, is it permissible to be selective on what items the patient will be
provided, and only provide those items with an acceptable reimbursement? >>
It would seem the legality is not clear, but there were some creative
answers. If a more definitive answer comes in I will share. Here are a few of
the replies:
Al, in some instances, I have explained to the patient that Medicare does not
allow for the cost of the item. The patient would pay me and Med would be
billed not accepting assignment so the payment would go directly to the
recipient. Of course if the patient has Medicaid backup, this isn't
possible.
Al, I have the same question. The problem is if you take assignment then you
get, what you get. If you don't then you can bill the item to the patient
less insurance.
Al, My understanding of the Medicare guidelines tells me the simple answer to
your question is no. I would appreciate it if you would forward any responses
indicating otherwise or offering a solution to the dilemma.
Al,
The way I have solved this dilemma in private practice seems to have worked
well. As you are probably aware, a facility has a choice whether or not to
be a participating provider with Medicare. This means you accept
assignment on whatever Medicare allows. The dilemma is that for those few
items that Medicare pays below the actual cost of the item....you eat the
difference or search for a cheaper alternative. In some cases there is no
less expensive alternative.
If you choose not to be a participating Medicare provider...you have agreed
to not accept assignment. Your facility can still operate as if they
accept assignment on what Medicare allows...with the exception of those
few items that you routinely take a loss on. At this point you inform the
patient that Medicare does not allow proper payment for you to dispense this
particular item. You also inform the patient that as a courtesy, you treat
the majority of your claims as if you accepted assignment. For those
claims that do not have a proper allowable, you as a business owner have
elected to exercise your right as a non-participating Medicare Provider,to
bill for the difference that Medicare does not allow.
This enables you to still use the item in which you think is best, or
present to the patient that a cheaper alternative will have to be
selected... If you chose the later, you will be able to treat the patients
claim as if you were accepting assignment. The former choice allows you more
latitude on what to provide but the patient has the final choice base on
whether he can afford the additional out of pocket expense. >>>>>>>>>>>>>>>>>>
>>>>>>>
Al Pike, CP
>> When Medicare reimbursement for a replacement item is below the cost of
the item, is it permissible to be selective on what items the patient will be
provided, and only provide those items with an acceptable reimbursement? >>
It would seem the legality is not clear, but there were some creative
answers. If a more definitive answer comes in I will share. Here are a few of
the replies:
Al, in some instances, I have explained to the patient that Medicare does not
allow for the cost of the item. The patient would pay me and Med would be
billed not accepting assignment so the payment would go directly to the
recipient. Of course if the patient has Medicaid backup, this isn't
possible.
Al, I have the same question. The problem is if you take assignment then you
get, what you get. If you don't then you can bill the item to the patient
less insurance.
Al, My understanding of the Medicare guidelines tells me the simple answer to
your question is no. I would appreciate it if you would forward any responses
indicating otherwise or offering a solution to the dilemma.
Al,
The way I have solved this dilemma in private practice seems to have worked
well. As you are probably aware, a facility has a choice whether or not to
be a participating provider with Medicare. This means you accept
assignment on whatever Medicare allows. The dilemma is that for those few
items that Medicare pays below the actual cost of the item....you eat the
difference or search for a cheaper alternative. In some cases there is no
less expensive alternative.
If you choose not to be a participating Medicare provider...you have agreed
to not accept assignment. Your facility can still operate as if they
accept assignment on what Medicare allows...with the exception of those
few items that you routinely take a loss on. At this point you inform the
patient that Medicare does not allow proper payment for you to dispense this
particular item. You also inform the patient that as a courtesy, you treat
the majority of your claims as if you accepted assignment. For those
claims that do not have a proper allowable, you as a business owner have
elected to exercise your right as a non-participating Medicare Provider,to
bill for the difference that Medicare does not allow.
This enables you to still use the item in which you think is best, or
present to the patient that a cheaper alternative will have to be
selected... If you chose the later, you will be able to treat the patients
claim as if you were accepting assignment. The former choice allows you more
latitude on what to provide but the patient has the final choice base on
whether he can afford the additional out of pocket expense. >>>>>>>>>>>>>>>>>>
>>>>>>>
Al Pike, CP
Citation
“Re: Below cost reimbursement,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 4, 2024, https://library.drfop.org/items/show/219004.
