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Ask-A-Consultant: Multiple Fee Schedules for Medicare & Insurance Carriers

Q:

I am a non-par doctor with Medicare and most other insurance carriers. I know for Medicare patients that I must submit all my bills at Medicare's Limiting Charge - but what about my other carriers. Can I maintain a regular higher fee schedule for everyone except Medicare and have a second "Medicare" fee schedule?
Palm Desert, CA

A:

Medicare & possible Medicaid in you state has statutory limits on how much you may bill. For Commercial payors you may submit your usual fees. However, if you have signed a contract accepting a plan's usual and customary or a negotiated fee schedule as payment in full, you cannot make the patient responsible for the difference between what you billed and what the plan allows. For example, a patient has an 80/20 contract for a service where you charge $500. If the plan's allowable fee is $300, you may only collect 20% of $300 not $500. If the service is not a benefit of the plan at all, then have the patient sign some form of advanced notice accepting responsibility for your usual change.
 

Karen M. Beard, CPC
Senior Associate

MMA does not provide legal, accounting, or tax advice.  If you need assistance in these areas, we recommend that you consult a qualified professional.  In addition, please note that a client relationship with MMA is not established by the submission of a question to this forum or by the publishing of MMA's response.



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Medical Management Associates, Inc.
3330 Cumberland Boulevard Suite 200 Atlanta, GA 30339
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