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Family Member Billing

  1. Default Family Member Billing
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    Are physicians prohibited from billing Medicare for all professional services provided to immediate family members. If so, I would appreciate the reference where this can be located.

  2. #2
    Dover Seacoast New Hampshire
    I do not believe that physicians are specifically prohibited from treating family members. That having been said, however, the usual federal guidelines would definitely apply when billing Medicare: medical necessity and fraud/abuse guidelines. For example, it would not be wise to waive copayments or bill for a condition that was not medically necessary or that was non-covered (like a cosmetic procedure). I can see where it might be tempting to write off grandma's copay.

    There's an ethical bend to this question, though, in terms of health boundaries. Too close for comfort, in my book, but not everyone has a problem with it, I guess.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. Default
    In my provided to immediate family members were not covered by Medicare. This may have been my misinterpretation of something I read in the Stark Law.

  4. Default
    Not allowed. Here is a paste from AMA

    Ethical questions have been raised about physicians who treat members of their own families. Incomplete physical examinations, medical records, and immunizations are undesirable consequences of physicians' treating their own children. The 1901 code of ethics of the American Medical Association (AMA) noted that a family member's illness tends to obscure the physician's judgement and produce patient timidity. In 1989, fearing financial abuse by unscrupulous providers, Medicare barred payment to physicians who care for "immediate family members."

    Who counts as a family member? Medicare's list of "immediate relatives" includes spouses, parents, children, siblings, stepparents, stepchildren, stepbrothers, stepsisters, children-in-law, siblings-in-law, grandparents, grandchildren, and spouses of grandparents or grandchildren. Since 1989, Medicare has not paid for patient care charges by immediately related physicians, their associates or their professional corporations. Blue Cross—Blue Shield, which has a stricter definition of "family member," has not paid for these charges since 1976.
    Last edited by sbicknell; 09-01-2010 at 11:59 PM.

  5. #5
    Dover Seacoast New Hampshire
    Can someone post the CMS link regarding treatment of family members? Thanks, Pam
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  6. #6
    North Carolina
    130 - Charges Imposed by Immediate Relatives of the Patient or Members of the Patient’s Household(Rev. 1, 10-01-03)
    A3-3161, HO-260.12, B3-2332
    A. General

    These are expenses that constitute charges by immediate relatives of the beneficiary or by members of their household. The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.

    The guideline goes into further detail...
    Rebecca CPC, CPMA, CEMC

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  7. Default
    Just to add an FYI -- in every (non-Medicare) policy I have ever read, there is an exclusion for services where there is no expectation for the patient to pay the doctor in the absence of insurance.

    In other words, unless you would bill your employees (or relatives and friends) your full fee, don't submit it to health insurance. And, if you only intend to collect what insurance pays and then waive the rest, it's fraud.
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    AMBACode Coding Software
    2015 AMBA National Medical Billing Conference

  8. #8
    We have a physician trying to bill services performed on himself, by himself. Same scenario I'm assuming?

  9. #9
    Quote Originally Posted by aleigh View Post
    We have a physician trying to bill services performed on himself, by himself. Same scenario I'm assuming?
    Correct. Even worse than billing for a family member.
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

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