Wiki Balance Billing...Need Some Insight! Help a Fellow Biller!

[mamador2]

Just going be straightforward and ask: When, if ever, is it legal and okay to balance bill Medicare patients? When is it okay to bill dual coverage Medicare patients with Medicaid or a commercial secondary insurance? This is excluding the Medicare yearly deductible, which, while we're on the subject, is it legal for an outpatient family practice clinic to bill the Medicare deductible as well? I was under the impression that Medicare/Medicaid pt's did not get any part of their bill with the exception of the Medicaid copay, and all non-covered charges are to be adjusted off when patient has active coverage for either or both. Please help me with this, need some wisdom. Have some stuff printed out that I'm going to research over the weekend, but anyone with seasoned knowledge/experience who can answer my questions would be greatly appreciated!

 

[Walker22]

If your practice accepts both Medicare and your state's Medicaid, then dual eligible patients can never be billed anything other than Medicaid copay, if that. If your practice does not accept Medicaid, and you inform the patient of this BEFORE providing services, then the patient will owe Medicare deductible and co-insurance.

 

[thomas7331]

I agree as a general rule, but would refer you to your state's Medicaid guidelines for details. Their Medicaid provider manual should give you the specific limitations of when it's allowable to bill the patient and that usually comes with the requirement that the patient is notified in advance.