Physician’s Right to Collect From Enrollee on Assigned Claim Submitted to Carriers
Before the Claim is Submitted
The provider (including physicians and suppliers) who is accepting assignment should not attempt to collect more than 20 percent of the charge from the enrollee when the deductible has been met. He or she should, if the occasion arises, be advised not to do so. Any greater amount collected will:
1. Reduce the amount payable to him/her on the assigned claim,
2. Cause the enrollee unnecessary hardship in raising the excess amount, and
3. Require extra work for the carrier in paying this excess to the enrollee instead of the physician.
However, a provider (including physicians and suppliers) may accept assignment after having collected a part of his/her bill. The fact that the enrollee has paid more than any deductible and coinsurance due does not invalidate the assignment.
Durable Medical Equipment Supplier Bills for Coinsurance at the Time Claim Submitted
Notwithstanding the guideline in C above, a supplier of durable medical equipment may bill the beneficiary for 20 percent of the Medicare allowed amount at the same time it submits an assigned claim to the carrier for the items and services furnished. The supplier must undertake:
1. To bill the beneficiary at the time it submits the claim only for 20 percent of the Medicare allowed amount; and
2. To 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 him/her self submit such a claim; and
b. The bill is for 20 percent of the Medicare allowable charge and is not covered by Medicare; and
3. To establish and maintain adequate procedures for refund of any over collections from the beneficiary that might result from the carrier approving a different Medicare allowed amount than that submitted.
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