Billing a Medicare patient

Hopefully this question is not off-topic for this board.

Physician sees a patient who has original Medicare, parts A and B. Physician does not accept Medicare assignment, but has not opted out of Medicare.

Physician has the patient sign an agreement prior to surgery agreeing to pay the physician $1,500 for the surgery. Patient give the physician the check in full amount as requested prior to surgery.

After the surgery, the physician submits a bill to Medicare for reimbursement. Medicare allows, say $800 for the surgery and sends the physician a check for 80%, $640.

The patient subsequently receives a MSN from Medicare two months later and discovers that Medicare has paid the doctor $640 in addition to the $1,500 that the patient also paid the doctor prior to the sx.

After continued prodding by the patient, the physician finally sends the patient a check five months later for the $640 he received from Medicare.

Question: Is the physician entitled to the entire $1,500 he received up front from the patient, or, since he billed Medicare on his own, for reimbursement for himself and not on the patient's behalf, is the physician subject to the Medicare limiting charge of 15% over 95% of Medicare's approved rate to his total reimbursement, which comes to around $950, and not the full $1,500?

Thanks so much.

Howie

re: Billing a Medicare patient

This is absolutely ridiculous (sorry to be so blunt). For starters, unless the physicians opts out of Medicare in writing, he/she cannot enter into a private contract with a patient under any circumstances. To not accept assignment bill, collect $1500.00 and have the patient have to beg for their money back is absurd. These types practices end you up wearing an orange jumpsuit, this physician is lucky thus far, the patient has not reported him/her to Medicare. If a physician does not want to accept Medicare that is fine, no problem but opt out officially and don't try to collect from both ends ---REALLY!!! The correct thing to do is refund the patient $860.00 as he NEVER should have entered into a private contract as he/she is participating with Medicare and that means he/she are accepting the fees! My intent is not to offend anyone but this one just burns me up!

re: Billing a Medicare patient

I have to agree. I'm sure this is a HIPAA violation and would be considered Medicare fraud.

re: Billing a Medicare patient

It is not legal for the physician to do that. If Medicare sent the check to the physician then that means he accepted assignment. The patient is entitled to a refund of 1500.00 minus his 20% co-pay of the allowed amount. My physician does not accept assignment either. When billing medicare the patient will get the check if the doctor doesnt accept assignment. If he got the check then that means he accepted assignment and he has to refund the patient. There are no outside contracts allowed, even if you dont accept assignment. You can do an ABN but you still cant bill the patient for more than Medicare allows.

re: Billing a Medicare patient

Thanks so much for the response.

Howard