Routine
Waiver Of Copayment Or Deductibles Under Medicare Part B by A. Maureen Hanna
Routine
Waiver Of Copayment Or Deductibles Under Medicare Part B
by A. Maureen Hanna
The Medicare "deductible" is the amount that must be paid by a Medicare beneficiary before Medicare will pay for any items or services for that individual. Currently, the Part B deductible is $100 per calendar year. In addition to a yearly deductible, the beneficiary is responsible for a 20% coinsurance payment. The 20% is due on almost all items covered by Medicare and is to be paid by the patient or supplemental insurance plan. Only covered, Medicare approved items or services are covered by the Medicare copayment requirements.
Anyone who routinely waives copayments
or deductibles can be criminally prosecuted under 42 U.S.C. 1320a-7b(b),
and excluded from participating in Medicare and State health care
programs under the anti-kickback statute. Additionally, submission
of a false claim to the Medicare program may be subject to criminal,
civil, or administrative liability for making false statements
and/or submitting false claims to the Government. Penalties can
include imprisonment, criminal fines, civil damages and forfeitures,
civil monetary penalties, and exclusion from Medicare and the
State health care programs.
A DME supplier may bill the beneficiary for 20% of the reasonable
charge at the same time it submits
an assigned claim to the carrier
for the items and services furnished.
However, the supplier must:
1) Bill the beneficiary at the time it submits the claim, only for 20% of the reasonable charge (e.g. allowable) as determined under the carrier's annual update.
2) Inform the beneficiary prominently
on its invoice that:
a. It has submitted a claim to the carrier for the items and services,
and he/she should not submit the claim.
b. The bill is for 20% of the Medicare allowable charge and is
not covered by Medicare.
3) Establish and maintain adequate procedures for refund of any over collections from the beneficiary which might result from the carrier approving a different reasonable charge than that submitted.
While all beneficiaries are expected to contribute the deductible and coinsurance amounts (or have it paid by another policy), there is, one important exception to the prohibition against waiving copayments and deductibles. Providers, practitioners, or suppliers may forgive the copayment in consideration of a particular patient's hardship. The hardship exception, however, must not be used routinely. It should be used occasionally to address the special financial needs of a particular patient.
Medicare requires a "reasonable collection effort" be made by the supplier to collect these amounts. Any supplier found to be routinely waiving these amounts risks having its Medicare allowable reduced by 20%, face fraud and abuse charges under the collect laws, and suspension from the Medicare program. A "reasonable collection effort" is defined as the effort the supplier puts forth to collect these amounts and must be comparable to non-Medicare patients.
HCFA states a beneficiary's indigence must be determined by the supplier and not by the patient. A patient's signed declaration of his/her inability to pay his/her medical bills is not considered proof of indigence.
One of the DMERCs (Cigna - Region D) has stated that on continuing monthly rentals you must make an attempt to collect each month. This information was published in the Fall 1999 DMERC Dialogue.
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