Medicare-and-The-Mystery-of-Collecting-Patient-Responsibility

Collecting From Medicare Patients at Time of Service?

The government has trained practices (the little guys) to be extremely cautious about making a misstep with Medicare patients. That is certainly their intention – to let you know that they have a zero tolerance policy on doing anything that could be construed as taking advantage of Medicare patients or the Medicare program itself.
Sometimes the way the government manages behavior is by being “silent” on what is acceptable.

The question is:
“Can I collect Co-pays, co-insurance and deductibles from Medicare patients prior to services being rendered?”

The answer is yes! They are estimated or calculated patient responsibility payments based on Medicare (or payers) published or contracted reimbursement rates, patient eligibility and benefit information available from Medicare (or Payer). Refer to “CMS Claims Processing Manual, Section 30.3.3.”

30.3.3 – Physician’s Right to Collect From Enrollee on Assigned Claim Submitted to Carriers
(Rev. 1, 10-01-03)
B3-3045.2

A. 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:

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.

B. Showing the Amount Collected on the Claims Form
In submitting an assigned claim, the provider (including physicians and suppliers) must show on Form CMS-1500 any amount he/she has collected from the enrollee for these services. This information is essential for correct payment of the benefits due; failure to show the amount paid is likely to result in excessive benefit payment to the provider (including physicians and suppliers) (i.e., if a benefit payment which, when added to the amount already paid by the enrollee, will exceed the Medicare allowed amount).

So, Medicare does allow you to collect the patient’s portion (co-insurance and deductibles) at the time of service. However, practices should have a formal process that assures a uniform and reliable methodology of determining the calculated or estimated patient portion.
Note the Medicare Claims Processing manual says that you can’t collect more than the patient owes – and if you do inadvertently, you must refund it promptly. It EXPLICITLY says that you can collect co-insurance and deductibles at the time of service. It’s acceptable if you have calculated the patient’s responsibility. To do this, you must have a process in place that assures a prompt refund if there are any overpayments.

Do not call these payments a “deposit”. Medicare does not allow you to collect a “deposit”. Then again, these payments are not arbitrary deposit amounts. They are calculated estimates of the patient’s out-of-pocket responsibility, based on published Medicare “allowed amounts” and “patient eligibility information” provided by Medicare.

Having Trouble with Patient Collections?
If your practice is struggling with what to collect at time of service, ask Exchange EDI about Automated Patient Settlement (APS) using an Account on File agreement. An account on file agreement allows your practice to automatically process the exact patient responsibility that is identified on the Medicare EOB. In addition, put the patients mind at ease by letting them know their debit or credit card is stored on a tokenized, secure, encrypted card processor server.

So stop sending statements and start getting paid within fifteen days (15) after the date-of-service. Now you can be in control of when you receive patient payments.

Reduce statement costs. Increase cash flow. Minimize bad debts and save staff time.