Wiki Self Pay Fee Schedule vs Insurance Fee Schedule

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Austin2477

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I know a physician who charges self pay patients $6000 for 90960 (ESRD srv 4 visits p mo 20+), but charges Medicare $292.01. The Medicare allowable for our region is $280.84. I completely disagree with this practice and find it unethical, but I can't find where it is illegal. Does anyone know if it is legal? Thanks in advance.
 
I did not take time to review the Medicare Manual reimbursement, or claims processing manual, false claims, HIPAA information, or OIG.

If the practice is audited, to defend the differences in prices, the practice needs to demonstrate how it takes more resources to treat/take care of a self-pay patient than a Medicare patient. Going from memory, I was always under the impression you cannot charge any patient differently than a Medicare Patient (under or below). You can have a policy that states you are charging Self-Pay patients the same rate as Medicare, and offering a S/P discount for payment in full.

You will also need to check with your State to see if you are required to charge the S/P patients the same price as the Medicaid Reimbursement.

I work at a facility and we are required to follow the 501R, set-forth by the IRS.

Is the practice under management of a hospital, if so, I encourage you to speak with your compliance officer.
 
Hi Austin,
I believe it also has to do whether the provider is a participating provider with Medicare, or not. However, the specific wording states that you can't give self-pay patients a more favorable rate than the medicare rate, but it looks like you can have it the other way around.
 
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