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If you have Original Medicare , your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of provider, meaning three different relationships a provider can have with Medicare . A provider’s type determines how much you will pay for Part B -covered services.

• These providers are required to submit a bill (file a claim ) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem .
• If you see a participating provider , you are responsible for paying a 20% coinsurance for Medicare-covered services.
• Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.
• Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge ). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.
• Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP) .
• If you pay the full cost of your care up front, your provider should still submit a bill to Medicare. Afterward, you should receive from Medicare a Medicare Summary Notice (MSN) and reimbursement for 80% of the Medicare-approved amount .
• The limiting charge rules do not apply to durable medical equipment (DME) suppliers . Be sure to learn about the different rules that apply when receiving services from a DME supplier .
• Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care.
• The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.
• Opt-out providers do not bill Medicare for services you receive.
• Many psychiatrists opt out of Medicare.

Providers who take assignment should submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date you received care. If your provider misses the filing deadline, they cannot bill Medicare for the care they provided to you. However, they can still charge you a 20% coinsurance and any applicable deductible amount.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool .

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Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services

Cristina Boccuti Published: Nov 30, 2016

• Issue Brief

Under current law, Medicare has several financial protections in place that are designed to safeguard Medicare beneficiaries—seniors and people with permanent disabilities—from unexpected and confusing charges when they seek care from doctors and other practitioners.  These protections include the participating provider program, limitations on balance billing, and conditions on private contracting.  This issue brief describes these three protections, explains why they were enacted, and examines the implications of modifying them for beneficiaries, providers, and the Medicare program.

Main Findings

• The participating provider program was enacted in 1984 for two purposes: (1) to assist Medicare patients with identifying and choosing providers who charge Medicare-approved rates; and (2) to encourage providers to accept these rates. Given this program’s strong provider incentives, the number of participating providers grew rapidly across all states and today, the vast majority (96%) of eligible physicians and practitioners are “participating providers”—agreeing to charge Medicare’s standard fees when they see beneficiaries.
• The Congress instituted limitations on balance billing in 1989, in conjunction with implementation of the Medicare physician fee schedule. This financial protection limits the amount that “non-participating” providers may charge beneficiaries through balance billing—whereby beneficiaries are responsible for the portion of the provider’s charge that exceeds Medicare’s fee-schedule rate. Total out-of-pocket liability from balance billing has declined significantly over the past few decades dropping from $2.5 billion in 1983 ($5.65 billion in 2011 dollars) to $40 million in 2011.
• In 1997, the Congress codified several conditions for private contracting that apply to physicians and practitioners who “opt out” of Medicare and see beneficiaries only under individual private contracts. These restrictions were instituted to ensure that beneficiaries are aware of the financial ramifications of entering into these private contracts, and to safeguard patients and Medicare from fraud and abuse.  In general, private contracting is relatively rare with only 1 percent of practicing physicians opting out of Medicare.

Background: Current Provider Options for Charging Medicare Patients

Under current law, physicians and practitioners have three options for how they will charge their patients in traditional Medicare.  They may register with Medicare as (1) a participating provider, (2) a non-participating provider, or (3) an opt-out provider who privately contracts with each of his or her Medicare patients for payment (Figure 1).  This issue brief describes these three options and then examines three current provisions in Medicare that provide financial protections for Medicare beneficiaries.

Participating providers:   Physicians and practitioners who register with Medicare as participating providers agree to “accept assignment” for all of their Medicare patients. Accepting assignment entails two conditions: agreeing to accept Medicare’s fee-schedule amount as payment-in-full for a given service and collecting Medicare’s portion directly from Medicare, rather than the patient. Therefore, when Medicare patients see participating providers, they can be certain that these providers will not charge fees higher than Medicare’s published fee-schedule amount and that they will not face higher out-of-pocket liability than the maximum 20-percent coinsurance for most services. The vast majority (96%) of providers who provide Medicare-covered services are participating providers.

Non-participating providers:   Non-participating providers do not agree to accept assignment for all of their Medicare patients; instead they may choose—on a service-by-service basis—to charge Medicare patients higher fees, up to a certain limit. When doing so, their Medicare patients are liable for higher cost sharing to cover the higher charges. This arrangement is called “balance billing” and means that the Medicare patient is financially responsible for the portion of the provider’s charge that is in excess of Medicare’s assigned rate, in addition to standard applicable coinsurance and deductibles for Medicare services.  When non-participating providers do not accept assignment, they may not collect reimbursement from Medicare; rather, they bill the Medicare patient directly, typically up front at the time of service. Non-participating providers must submit claims to Medicare on behalf of their Medicare patients, but Medicare reimburses the patient, rather than the nonparticipating provider, for its portion of the covered charges.  A small share (4%) of providers who provide Medicare-covered services are non-participating providers.

Opt-out providers, privately contracting:   Physicians and practitioners who choose to enter into private contracts with their Medicare patients “opt-out” of the Medicare program entirely. These opt-out providers may charge Medicare patients any fee they choose. Medicare does not provide any reimbursement—either to the provider or the Medicare patient—for services provided by these providers under private contracts. Accordingly, Medicare patients are liable for the entire cost of any services they receive from physicians and practitioners who have opted out of Medicare. Several protections are in place to ensure that patients are clearly aware of their financial liabilities when seeing a provider under a private contract.  An extremely small portion of physicians (less than 1% of physicians in clinical practice) have chosen to “opt-out” of the Medicare program, of whom 42 percent are psychiatrists.

These provider options have direct implications on the charges and out-of-pocket liabilities that beneficiaries face when they receive physician services (Figure 2).  They also play a major role in several financial protections in current law—namely, the physician participation program, limitations on balance billing, and conditions for private contracting—which help beneficiaries understand the financial implications of their provider choices and encourage providers to accept Medicare’s standard fees.

Figure 1: Physician/Practitioner Billing Options in Traditional Medicare

Figure 2: Medicare reimbursement and beneficiary cost-sharing for a $100 fee-schedule service

Medicare’s Participating Provider Program

Medicare’s participating provider program includes several incentives (both financial and nonfinancial) to encourage physicians and practitioners to “accept assignment” for all of their Medicare patients.  When providers accept assignment, they agree to accept Medicare’s fee-schedule amount as payment-in-full for a given service and are allowed to bill Medicare directly for its portion of the reimbursement.  Physicians and practitioners who agree to accept assignment on all services that they provide to Medicare patients are “participating providers” and are listed in Medicare provider directories.  Beneficiaries who select a participating provider are assured that, after meeting the deductible, their coinsurance liability will not exceed 20 percent of the charge for the services they receive (Figure 2).

Congress established the participating provider program in the 1984 Deficit Reduction Act (DEFRA) to address two main concerns: confusion among beneficiaries about the fees they were being charged when they saw a doctor and escalating rates of balance billing from charges that exceeded Medicare’s established “usual, customary, and reasonable” rates for their area. 1 At that time, aside from Medicaid-eligible beneficiaries, Medicare had no limits on the amount that physicians and practitioners could balance bill for their services. Surveys conducted by the Physician Payment Review Commission (PPRC), a congressional advisory body and predecessor of the Medicare Payment Advisory Commission (MedPAC), revealed that prior to the participating provider program, beneficiaries often did not know from one physician to the next whether they would face extra out-of-pocket charges due to balance billing and how much those amounts might be. 2   By 1984, beneficiaries’ payment for balance billing reached 27 percent of total Medicare Part B out-of-pocket liability and was jeopardizing their access to affordable physician services. 3

The establishment of the participating provider program in Medicare instituted multiple incentives to encourage providers to accept assignment for all their patients and become participating providers.  For example, Medicare payment rates for participating providers are 5 percent higher than the rates paid to non-participating providers.  Also, participating providers may collect Medicare’s reimbursement amount directly from Medicare, in contrast to non-participating providers who may not collect payment from Medicare and typically bill their Medicare patients upfront for their charges.  (Non-participating providers must submit claims to Medicare so that their patients are reimbursed for Medicare’s portion of their charges.) Participating providers also gain the benefit of having electronic access to Medicare beneficiaries’ supplemental insurance status, such as their Medigap coverage. This information makes it considerably easier for providers to file claims to collect beneficiary coinsurance amounts, as well as easing the paperwork burden on patients.  Additionally, Medicare helps beneficiaries in traditional Medicare seek and select participating providers by listing them by name with their contact information on Medicare’s consumer-focused website (www.Medicare.gov).

Given the strong incentives of the participation program, combined with limits on balance billing (discussed in the next section), it is not surprising that the share of physicians and practitioners electing to be participating providers has risen to high levels across the country. Overall, the rate of providers with participation agreements has grown to 96 percent in 2011, up considerably from about 30 percent in 1986, two years after the start of the participating provider program (Figure 3). 4   As a result, across all states, most beneficiaries now encounter predictable expenses for Medicare-covered services, and are never responsible for Medicare’s portion of the fee (Appendix 1).

Figure 3: Strong incentives in Medicare have led to a high rate of “participating providers”

Medicare’s Balance Billing Limitations

Despite the incentives to become participating providers, a small share (4%) of physicians and practitioners who are registered with Medicare are non-participating providers. These providers can—on a service-by-service basis—charge patients in traditional Medicare higher fees than Medicare’s fee-schedule amount, up to a specified maximum. When charging higher fees, beneficiaries are responsible for the difference between Medicare’s approved amount and the providers’ total charge—essentially the balance of the bill remaining after accounting for Medicare’s reimbursement. This higher cost-sharing arrangement is called “balance billing” and means that the Medicare patient is financially liable for not only the applicable coinsurance and deductible, but also for any amount in which the provider’s charge exceeds Medicare’s assigned rate. Providers may not balance bill Medicare beneficiaries who also have Medicaid coverage. 5

When non-participating providers balance bill, they bill the beneficiary directly, typically for the full charge of the service—including Medicare’s share, applicable coinsurance and deductible, and any balance billed amount.  Non-participating providers are then required to submit a claim to Medicare, so that Medicare can process the claim and reimburse the patient for Medicare’s share of the charge.  Two Medigap insurance policies, which beneficiaries may purchase to supplement their Medicare coverage, include coverage for balance billing. 6   Balance billing is prohibited for Medicare-covered services in the Medicare Advantage program, except in the case of private fee-for-service plans.

In traditional Medicare, the maximum that non-participating providers may charge for a Medicare-covered service is 115 percent of the discounted fee-schedule amount. (Medicare’s fee-schedule rates for non-participating physicians are reduced by five percent.)  Accordingly, non-participating providers may bill Medicare patients up to 9.25 percent more than participating providers (i.e., 1.15 x 0.95= 109.25).  If the non-participating physician or practitioner balance bills the maximum amount permitted (not including any unmet deductible), total beneficiary liability for Medicare-covered services is about 33 percent of Medicare’s regular fee schedule amount (Figure 2).

Balance billing limitations were implemented in conjunction with the institution of Medicare’s physician fee-schedule in the Omnibus Budget Reconciliation Act of 1989.  At the time, Medicare’s charge-based methodology for physician services gave rise to rapid spending growth and confusion among beneficiaries about what charges they would face for physician services. 7 Moreover, high cost-sharing liabilities weighed disproportionately on beneficiaries who were sickest and used the most physician services. Despite physician reports that they took patient incomes into account when determining whether to charge higher-than Medicare rates, PPRC research did not find a relationship between beneficiary income and the probability that claims would be assigned. 8

While the Congress constrained growth in provider fees through the implementation of the fee schedule, it also implemented maximum “limiting charges” to establish further certainty and predictability for patients on their expected costs for services. In trying to rein in Medicare fee-schedule payments, the Congress sought to protect beneficiaries from excess charges that providers could otherwise impose in response to restrictions on their fees. 9

The continued desire to protect beneficiary spending during the implementation of the new physician fee schedule gave rise to the question of whether Congress might consider imposing even greater restrictions on balance billing or even mandate assignment (prohibiting balance billing) for all claims. 10 Ultimately, the rationale in Congress for allowing limited balance billing was that it would provide for:  (1) a “safety valve” for physicians who believed that the fee schedule did not adequately reflect the quality of services that they provided; (2) a means to correct any underpricing of resource costs in the fee schedule; and (3) necessary financial protections for beneficiaries, particularly in areas of the country where choice of physicians was limited. 11

As limits on balance billing were implemented and incentives for physicians and practitioners to take assignment took hold, beneficiary liability for balance billing declined dramatically.  CMS data show that in 2011, total balance billing amounted to $40 million, down significantly from $2.5 billion in 1983, (which equals $5.6 billion in 2011 dollars) (Figure 4).  Concurrently, the rate of assigned claims to total covered charges climbed from 51% in 1983 to 99% in 2011.

Figure 4: Balance billing in Medicare has declined significantly; almost all physician services are now paid on assignment

Private Contracting Conditions for Providers who Opt Out of Medicare

A very small share of providers (less than 1 percent of physicians) have elected to “opt out” of Medicare and contract privately with all of their Medicare patients, individually. 12 Their fees are not bound by Medicare’s physician fee schedule in any way, which means that these providers have no limits on the amounts they may charge beneficiaries for their services.  Medicare does not reimburse either the provider or the patient for any services furnished by opt-out providers.  Therefore, Medicare patients are financially responsible for the full charge of services provided by providers who have formally opted out of Medicare. 13

Serving as beneficiary protections, several important conditions exist for providers who elect to contract privately with Medicare patients. One condition is that prior to providing any service to Medicare patients, physicians and practitioners must inform their Medicare patients that they have opted out of Medicare and provide their Medicare patients with a written document stating that Medicare will not reimburse either the provider or the patient for any services furnished by opt-out providers. Their Medicare patients must sign this document to signify their understanding of it and their right to seek care from a physician or other practitioner who has not opted-out of Medicare.

Providers opt-out by submitting a signed affidavit to Medicare agreeing to applicable terms and affirming that their contracts with patients include all the necessary information.  Physicians or practitioners who opt out of Medicare must privately contract with all of their Medicare patients, not just some.  Once a physician or practitioner opts out of Medicare, this status lasts for a two-year period and is automatically renewed unless the physician or practitioner actively cancels it. 14   Providers may not enter into a private contract with a beneficiary who also has Medicaid benefits or who is experiencing an urgent or emergent health care event. 15

These conditions, which provide protections for both beneficiaries and the Medicare program, were included in the Balanced Budget Act of 1997 as part of the legislation that first codified physicians’ ability to privately contract with Medicare beneficiaries.  Requiring opt-out providers to privately contract for all services they provide to Medicare patients (rather than being able to select by individual patients or services) was intended to prevent confusion among Medicare patients as to whether or not each visit would be covered under Medicare and how much they could expect to pay out-of-pocket.  Similarly, requiring providers to opt out for a minimum period of time—two years—was intended to ensure that beneficiaries had consistent information to make knowledgeable choices when selecting their physicians.  Both of these provisions also addressed Medicare’s duty to guard against fraudulent billing in an administratively feasibly manner.  If, for example, physicians contracted with only some of their patients and/or services, Medicare would have to examine each contract for each submitted claim to discern which claims were eligible for Medicare reimbursement and which were not.

Previous Kaiser Family Foundation analysis shows that psychiatrists are disproportionately represented among the 0.7 percent of physicians (4,863) who have opted out of Medicare—comprising 42 percent of all physicians who have opted out (Figure 5). 16   Another 1,775 clinical professionals with non-physician doctorate degrees (i.e. oral surgeon dentists, podiatrists, and optometrists) also have opted-out of the Medicare program. 17 Dentists who are oral surgeons comprise the majority of this group (95%).  Earlier research that examined opt-out providers through 2002 found similarly low numbers of providers opting out (2,839) as well as relatively higher opt-out rates among psychiatrists compared with other specialties. 18

Some physician organizations attribute physician decisions to opt out of Medicare to frustration with Medicare’s fees and regulations. 19 Others have noted a similar trend in physician refusal to work with any insurers—including commercial insurance plans—especially in prosperous communities. 20 In these cases, providers require patients to pay them directly out-of-pocket, leaving the patient to seek reimbursement, if any, from their insurer.  For providers with patients who have the resources to make the payments, this billing method significantly reduces providers’ paperwork.

Concierge Practice Models

Some physicians are turning to concierge practice models (also called retainer-based care), in which they charge their patients annual membership fees and typically have smaller patient caseloads.  Physicians in a concierge practice model do not necessarily need to opt-out of Medicare to see Medicare patients.  However, if they do not opt-out of Medicare, these physicians are subject to Medicare’s balance billing rules, and therefore, cannot charge beneficiaries additional fees for services that are already covered by Medicare. 21 For example, the annual fee for a concierge practice may not be used for the yearly wellness visit covered by Medicare, but it could be applied to items such as a newsletter and high-end waiting room furniture.  More controversy exists about concierge practices applying annual fees paid by Medicare beneficiaries to enhanced appointment access and extra time with patients. 22

While anecdotal reports suggest a significant migration of primary care physicians to concierge/retainer practices, particularly in areas around Washington D.C and other major east and west coast cities, reliable data on the number of these practices are lacking.  In 2010, a report for MedPAC found listings for 756 concierge physicians, compared with 146 found by Government Accountability Office in 2005. 23   Other news articles have reported larger numbers (4,400 in 2012) according to the American Association of Private Physicians. 24

Implications of Proposals to Modify Incentives and Relax Certain Financial Protections—Pros and Cons

Proposals introduced by Rep. Tom Price, House Speaker Paul Ryan and others have sought to relax private contracting conditions either throughout the Medicare program or as a demonstration project that could be implemented by the Administration.  For example, in 2015, two Bills introduced in the House with a companion Bill in the Senate 25 include provisions to allow physicians and practitioners to engage in private contracting on a beneficiary-by-beneficiary basis, instead of requiring providers to opt-out of Medicare entirely. These Bills would also allow beneficiaries to seek Medicare reimbursement for the portion of the privately contracted fee that equals Medicare’s fee schedule amount, but no out-of-pocket limits would apply to the remaining portion of the provider’s charge.  Similar changes are also proposed as a demonstration in the 2016 House Republican Plan, “A Better Way, our Vision for a Confident America.” 26   An earlier House Bill also included a demonstration to allow non-participating providers to collect Medicare’s portion of their charge directly from Medicare. 27

Pros: Support for Relaxing restrictions and increasing physician autonomy

Proponents of such proposals, including the American Medical Association, support relaxing restrictions on balance billing and private contracting for a number of reasons—perhaps the foremost is that they would allow physicians to charge Medicare beneficiaries higher rates and thereby get relief from fees that they say have failed to keep pace with the rising costs of running their practices. 28   Proponents also assert that this ability could increase the overall number of providers willing to accept Medicare patients. This concern may be an issue in some geographic areas, though surveys and other data sources show that nationally, access to physicians among Medicare seniors is generally comparable to access among people age 55 to 64 with private insurance. 29

Physician groups also state that proposals to relax constraints on balance billing and private contracting would give providers a sense of greater autonomy in how they relate to both their patients and the Medicare program and would allow physicians to charge higher fees to some patients based on their assessment of their patients’ ability to pay. 30   Additionally, beneficiaries would be able to seek at least partial Medicare reimbursement for services they received under private contracts.  Proposals that would allow non-participating providers to collect Medicare’s portion of their charge directly from Medicare would obviate the need to charge patients the full fee upfront. This circumstance could be helpful to those patients who do not want to wait for Medicare’s reimbursement, even if on net, they would incur higher out-of-pocket liability due to balance billing.  Non-participating providers could also experience a more reliable payment from Medicare, compared with the challenges, in some cases, of collecting fees from Medicare patients for unassigned claims.

Cons: Concerns about Eroding Financial Protections

Other analysts have raised concerns about the effects of relaxing private contracting rules and balance billing restrictions. 31   To the extent that such changes lead to increases in the number of non-participating and/or opt-out providers, they could exacerbate problems that lower-income beneficiaries face when seeking care.  Beneficiaries without the ability to pay higher rates (who are also likely to be disproportionately sicker) could find a reduced pool of physicians willing to accept them. Also, for rarer physician specialties and in some geographic areas, such as rural parts of the country, patients may have little choice among physicians.  If the limits on balance billing and private contracting were relaxed, beneficiaries in these situations could face the types of problems that existed prior to the imposition of limits on balance billing—high out-of-pocket costs and greater confusion and uncertainty about possible charges.  Additionally, concerns have been raised about the accuracy and appropriateness of providers determining which Medicare patients in their caseload can afford higher fees, and by how much.

While proposals that allow beneficiaries and non-participating physicians to seek reimbursement from Medicare may, in the short term, reduce out-of-pocket liability for beneficiaries, they could also decrease the incentives for physicians and practitioners to become participating providers.  In the long run, if significantly more providers balance billed their Medicare patients or opted-out of Medicare, this shift could alternatively increase beneficiary out-of-pocket spending.

From the perspective of the Medicare’s program integrity, Medicare would have significant difficulty tracking fraud and abuse if physicians were able to contract selectively for services with some but not all beneficiaries.  Medicare would have to examine every physician-patient contract, on a claim-by-claim basis, to determine which claims could be reimbursed directly to the physician and which would be the full responsibility of the patient.  Additionally, Medicare would need to examine these physicians’ billing practices to ensure that beneficiaries were not being charged inappropriately.

Conclusions

Balance billing limits, with incentives for physicians to accept assignment, have proven effective in limiting beneficiaries’ out-of-pocket liability for physician services. Today, a small share of Medicare beneficiaries experience balance billing just as only small share of provider claims in Medicare are paid unassigned—very different from the years before balance billing limits were instituted.  Moreover, only about 1 percent of physicians provide services to beneficiaries on a private contracting basis.  As the Congress has been considering changes to the way in which Medicare pays for physician service in the context of SGR repeal, some proposals have briefly surfaced to relax constraints on balance billing and private contracting.

On the one hand, these proposals could increase physician autonomy and provider willingness to treat Medicare patients, particularly among those providers who charge higher fees. On the other hand, such proposals could result in higher out-of-pocket liability, particularly in the longer term, which could affect beneficiary access to care.  Additionally, relaxing these protections could foster less predictability in the fees beneficiaries encounter when seeing physicians and practitioners.  Patients most at risk for experiencing a greater financial burden would be those with modest incomes and greater health care needs.  Beneficiaries in geographic areas with limited choices of physicians might also be at higher risk if a growing number of providers choose to balance bill or require private contracts with their Medicare patients.  The key is to strike a balance between assuring that providers receive fair payments from Medicare while also preserving financial protections that help beneficiaries face more predictable and affordable costs when they seek care.

Technical support in preparation of this brief was provided by Health Policy Alternatives, Inc.

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Medicare Assignment: Understanding How It Works

Medicare assignment is a term used to describe how a healthcare provider agrees to accept the Medicare-approved amount. Depending on how you get your Medicare coverage, it could be essential to understand what it means and how it can affect you.

What is Medicare assignment?

Medicare sets a fixed cost to pay for every benefit they cover. This amount is called Medicare assignment.

You have the largest healthcare provider network with over 800,000 providers nationwide on Original Medicare . You can see any doctor nationwide that accepts Medicare.

Understanding the differences between your cost and the difference between accepting Medicare and accepting Medicare assignment could be worth thousands of dollars.

Doctors that accept Medicare

Your healthcare provider can fall into one of three categories:

Medicare participating provider and Medicare assignment

Medicare participating providers not accepting medicare assignment, medicare non-participating provider.

More than 97% of healthcare providers nationwide accept Medicare. Because of this, you can see almost any provider throughout the United States without needing referrals.

Let’s discuss the three categories the healthcare providers fall into.

Participating providers are doctors or healthcare providers who accept assignment. This means they will never charge more than the Medicare-approved amount.

Some non-participating providers accept Medicare but not Medicare assignment. This means you can see them the same way a provider accepts assignment.

You need to understand that since they don’t take the assigned amount, they can charge up to 15% more than the Medicare-approved amount.

Since Medicare will only pay the Medicare-approved amount, you’ll be responsible for these charges. The 15% overcharge is called an excess charge. A few states don’t allow or limit the amount or services of the excess charges. Only about 5% of providers charge excess charges.

Opt-out providers don’t accept Original Medicare, and these healthcare providers are in the minority in the United States. If healthcare providers don’t accept Medicare, they won’t be paid by Medicare.

This means choosing to see a provider that doesn’t accept Medicare will leave you responsible for 100% of what they charge you. These providers may be in-network for a Medicare Advantage plan in some cases.

Avoiding excess charges

Excess charges could be large or small depending on the service and the Medicare-approved amount. Avoiding these is easy. The simplest way is to ask your provider if they accept assignment before service.

If they say yes, they don’t issue excess charges. Or, on Medicare.gov , a provider search tool will allow you to look up your healthcare provider and show if they accept Medicare assignment or not.

Medicare Supplement and Medicare assignment

Medigap plans are additional insurance that helps cover your Medicare cost-share . If you are on specific plans, they’ll pay any extra costs from healthcare providers that accept Medicare but not Medicare assigned amount. Most Medicare Supplement plans don’t cover the excess charges.

The top three Medicare Supplement plans cover excess charges if you use a provider that accepts Medicare but not Medicare assignment.

Medicare Advantage and Medicare assignment

Medicare assignment does not affect Medicare Advantage plans since Medicare Advantage is just another way to receive your Medicare benefits. Since your Medicare Advantage plan handles your healthcare benefits, they set the terms.

Most Medicare Advantage plans require you to use network providers. If you go out of the network, you may pay more. If you’re on an HMO, you’d be responsible for the entire charge of the provider not being in the network.

Do all doctors accept Medicare Supplement plans?

All doctors that accept Original Medicare accept Medicare Supplement plans. Some doctors don’t accept Medicare. In this case, those doctors won’t accept Medicare Supplements.

Where can I find doctors who accept Medicare assignment?

Medicare has a physician finder tool that will show if a healthcare provider participates in Medicare and accepts Medicare assignments. Most doctors nationwide do accept assignment and therefore don’t charge the Part B excess charges.

Why do some doctors not accept Medicare?

Some doctors are called concierge doctors. These doctors don’t accept any insurance and require cash payments.

What is a Medicare assignment?

Accepting Medicare assignment means that the healthcare provider has agreed only to charge the approved amount for procedures and services.

What does it mean if a doctor does not accept Medicare assignment?

The doctor can change more than the Medicare-approved amount for procedures and services. You could be responsible for up to a 15% excess charge.

How many doctors accept Medicare assignment?

About 97% of doctors agree to accept assignment nationwide.

Is accepting Medicare the same as accepting Medicare assignment?

No. If a doctor accepts Medicare and accepts Medicare assigned amount, they’ll take what Medicare approves as payment in full.

If they accept Medicare but not Medicare assignment, they can charge an excess charge of up to 15% above the Medicare-approved amount. You could be responsible for this excess charge.

What is the Medicare-approved amount?

The Medicare-approved amount is Medicare’s charge as the maximum for any given medical service or procedure. Medicare has set forth an approved amount for every covered item or service.

Can doctors balance bill patients?

Yes, if that doctor is a Medicare participating provider not accepting Medicare assigned amount. The provider may bill up to 15% more than the Medicare-approved amount.

What happens if a doctor does not accept Medicare?

Doctors that don’t accept Medicare will require you to pay their full cost when using their services. Since these providers are non-participating, Medicare will not pay or reimburse for any services rendered.

Get help avoiding Medicare Part B excess charges

Whether it’s Medicare assignment, or anything related to Medicare, we have licensed agents that specialize in this field standing by to assist.

Give us a call, or fill out our online request form . We are happy to help answer questions, review options, and guide you through the process.

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Medicare Options

To help ensure that physicians are making informed decisions about their contractual relationships with the Medicare program, the AMA has developed a “Medicare Participation Kit”(www.ama-assn.org) that explains the various participation options that are available to physicians. A summary of those options is presented below. The AAFP is not advising or recommending any of the options. The purpose of sharing this information is merely to ensure that physician decisions about Medicare participation are made with complete information about the available options. Please note that the summary below does not account for any payment adjustments that a participating or non-participating physician may incur through one of the Medicare initiatives, such as the Physician Quality Reporting System. Physicians wishing to change their Medicare participation or non-participation status for a given year are usually required to do so by December 31 of the prior year (e.g., December 31, 2015 for 2016). Participation decisions are effective January 1 of the year in question and are binding for the entire year.

The Three Options

There are basically three Medicare contractual options for physicians. Physicians may sign a participating (PAR) agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients. They may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Or they may become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves. Physicians who wish to change their status from PAR to non-PAR or vice versa may do so annually. Once made, the decision is generally binding until the next annual contracting cycle except where the physician's practice situation has changed significantly, such as relocation to a different geographic area or a different group practice. To become a private contractor, physicians must give 30 days notice before the first day of the quarter the contract takes effect. Those considering a change in status should first determine that they are not bound by any contractual arrangements with hospitals, health plans or other entities that require them to be PAR physicians. In addition, some states have enacted laws that prohibit physicians from balance billing their patients.

Participation

PAR physicians agree to take assignment on all Medicare claims, which means that they must accept Medicare's approved amount (which is the 80% that Medicare pays plus the 20% patient copayment) as payment in full for all covered services for the duration of the calendar year. The patient or the patient's secondary insurer is still responsible for the 20% copayment but the physician cannot bill the patient for amounts in excess of the Medicare allowance. While PAR physicians must accept assignment on all Medicare claims, however, Medicare participation agreements do not require physician practices to accept every Medicare patient who seeks treatment from them.

Medicare provides a number of incentives for physicians to participate:

• The Medicare payment amount for PAR physicians is 5% higher than the rate for non-PAR physicians.
• Directories of PAR physicians are provided to senior citizen groups and individuals who request them.
• Medicare administrative contractors (MAC) provide toll-free claims processing lines to PAR physicians and process their claims more quickly.

Non-Participation

Medicare approved amounts for services provided by non-PAR physicians (including the 80% from Medicare plus the 20% copayment) are set at 95% of Medicare approved amounts for PAR physicians, although non-PAR physicians can charge more than the Medicare approved amount.

Limiting charges for non-PAR physicians are set at 115% of the Medicare approved amount for non-PAR physicians. However, because Medicare approved amounts for non-PAR physicians are 95% of the rates for PAR physicians, the 15% limiting charge is effectively only 9.25% above the PAR approved amounts for the services. Therefore, when considering whether to be non-PAR, physicians must determine whether their total revenues from Medicare, patient copayments and balance billing would exceed their total revenues as PAR physicians, particularly in light of collection costs, bad debts and claims for which they do accept assignment. The 95% payment rate is not based on whether physicians accept assignment on the claim, but whether they are PAR physicians; when non-PAR physicians accept assignment for their low-income or other patients, their Medicare approved amounts are still only 95% of the approved amounts paid to PAR physicians for the same service. Non-PAR physicians would need to collect the full limiting charge amount roughly 35% of the time they provided a given service in order for the revenues from the service to equal those of PAR physicians for the same service. If they collect the full limiting charge for more than 35% of the services that they provide, their Medicare revenues will exceed those of PAR physicians.

Assignment acceptance, for either PAR or non-PAR physicians, also means that the MAC pays the physician the 80% Medicare payment. For unassigned claims, even though the physician is required to submit the claim to Medicare, the program pays the patient, and the physician must then collect the entire amount for the service from the patient.

Example: A service for which Medicare fee schedule amount is $100

Private contracting.

Provisions in the Balanced Budget Act of 1997 give physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system. Private contracting decisions may not be made on a case-by-case or patient-by-patient basis, however. Once physicians have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.

A physician who has not been excluded under sections 1128, 1156 or 1892 of the Social Security Act may, however, order, certify the need for, or refer a beneficiary for Medicare-covered items and services, provided the physician is not paid, directly or indirectly, for such services (except for emergency and urgent care services). For example, if a physician who has opted out of Medicare refers a beneficiary for medically necessary services, such as laboratory, DMEPOS or inpatient hospitalization, those services would be covered by Medicare.

To privately contract with a Medicare beneficiary, a physician must enter into a private contract that meets specific requirements, as set forth in the sample private contract below. In addition to the private contract, the physician must also file an affidavit that meets certain requirements, as contained in the sample affidavit below. To opt out, a physician must file an affidavit that meets the necessary criteria and is received by the MAC at least 30 days before the first day of the next calendar quarter. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out.

Emergency and Urgent Care Services Furnished During the "Opt-Out" Period

Physicians who have opted-out of Medicare under the Medicare private contract provisions may furnish emergency care services or urgent care services to a Medicare beneficiary with whom the physician has previously entered into a private contract so long as the physician and beneficiary entered into the private contract before the onset of the emergency medical condition or urgent medical condition. These services would be furnished under the terms of the private contract.

Physicians who have opted-out of Medicare under the Medicare private contract provisions may continue to furnish emergency or urgent care services to a Medicare beneficiary with whom the physician has not previously entered into a private contract, provided the physician:

• Submits a claim to Medicare in accordance with both 42 CFR part 424 (relating to conditions for Medicare payment) and Medicare instructions (including but not limited to complying with proper coding of emergency or urgent care services furnished by physicians and qualified health care professionals who have opted-out of Medicare).
• Collects no more than the Medicare limiting charge, in the case of a physician (or the deductible and coinsurance, in the case of a qualified health care professional).

Note that a physician who has been excluded from Medicare must comply with Medicare regulations relating to scope and effect of the exclusion (42 C.F.R. § 1001.1901) when the physician furnishes emergency services to beneficiaries, and the physician may not bill and be paid for urgent care services.

Sample Medicare Private Contract and Affidavit

The sample private contract and affidavit below contain the provisions that Medicare requires (unless otherwise noted) to be included in these documents.

Private contracts must meet specific requirements:

• The physician must sign and file an affidavit agreeing to forgo receiving any payment from Medicare for items or services provided to any Medicare beneficiary for the following 2-year period (either directly, on a capitated basis or from an organization that received Medicare reimbursement directly or on a capitated basis).
• Medicare does not pay for the services provided or contracted for. The contract must be in writing and must be signed by the beneficiary before any item or service is provided.
• The contract cannot be entered into at a time when the beneficiary is facing an emergency or an urgent health situation.

In addition, the contract must state unambiguously that by signing the private contract, the beneficiary:

• gives up all Medicare payment for services furnished by the "opt out" physician;
• agrees not to bill Medicare or ask the physician to bill Medicare;
• is liable for all of the physician's charges, without any Medicare balance billing limits;
• acknowledges that Medigap or any other supplemental insurance will not pay toward the services; and acknowledges that he or she has the right to receive services from physicians for whom Medicare coverage and payment would be available.

If you determine that you want to "opt out" of Medicare under a private contract, we recommend that you consult with your attorney to develop a valid contract containing other standard non-Medicare required provisions that generally are included in any standard contract.

Download sample contracts:

• Sample Medicare Private Contract
• Sample Medicare Private Contracts "Opt-Out" Affidavit

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What Is a Collateral Assignment of Life Insurance?

Charlene Rhinehart is a CPA , CFE, chair of an Illinois CPA Society committee, and has a degree in accounting and finance from DePaul University.

A collateral assignment of life insurance is a conditional assignment appointing a lender as an assignee of a policy. Essentially, the lender has a claim to some or all of the death benefit until the loan is repaid. The death benefit is used as collateral for a loan.

The advantage to using a collateral assignee over naming the lender as a beneficiary is that you can specify that the lender is only entitled to a certain amount, namely the amount of the outstanding loan. That would allow your beneficiaries still be entitled to any remaining death benefit.

Lenders commonly require that life insurance serve as collateral for a business loan to guarantee repayment if the borrower dies or defaults. They may even require you to get a life insurance policy to be approved for a business loan.

Key Takeaways

• The borrower of a business loan using life insurance as collateral must be the policy owner, who may or may not be the insured.
• The collateral assignment helps you avoid naming a lender as a beneficiary.
• The collateral assignment may be against all or part of the policy's value.
• If any amount of the death benefit remains after the lender is paid, it is distributed to beneficiaries.
• Once the loan is fully repaid, the life insurance policy is no longer used as collateral.

How a Collateral Assignment of Life Insurance Works

Collateral assignments make sure the lender gets paid only what they are due. The borrower must be the owner of the policy, but they do not have to be the insured person. And the policy must remain current for the life of the loan, with the policy owner continuing to pay all premiums . You can use either term or whole life insurance policy as collateral, but the death benefit must meet the lender's terms.

A permanent life insurance policy with a cash value allows the lender access to the cash value to use as loan payment if the borrower defaults. Many lenders don't accept term life insurance policies as collateral because they do not accumulate cash value.

Alternately, the policy owner's access to the cash value is restricted to protect the collateral. If the loan is repaid before the borrower's death, the assignment is removed, and the lender is no longer the beneficiary of the death benefit.

Insurance companies must be notified of the collateral assignment of a policy. However, other than their obligation to meet the terms of the contract, they are not involved in the agreement.

Example of Collateral Assignment of Life Insurance

For example, say you have a business plan for a floral shop and need a $50,000 loan to get started. When you apply for the loan, the bank says you must have collateral in the form of a life insurance policy to back it up. You have a whole life insurance policy with a cash value of $65,000 and a death benefit of $300,000, which the bank accepts as collateral.

So, you then designate the bank as the policy's assignee until you repay the $50,000 loan. That way, the bank can ensure it will be repaid the funds it lent you, even if you died. In this case, because the cash value and death benefit is more than what you owe the lender, your beneficiaries would still inherit money.

Alternatives to Collateral Assignment of Life Insurance

Using a collateral assignment to secure a business loan can help you access the funds you need to start or grow your business. However, you would be at risk of losing your life insurance policy if you defaulted on the loan, meaning your beneficiaries may not receive the money you'd planned for them to inherit.

Consult with a financial advisor to discuss whether a collateral assignment or one of these alternatives may be most appropriate for your financial situation.

Life insurance loan (policy loan) : If you already have a life insurance policy with a cash value, you can likely borrow against it. Policy loans are not taxed and have less stringent requirements such as no credit or income checks. However, this option would not work if you do not already have a permanent life insurance policy because the cash value component takes time to build.

Surrendering your policy : You can also surrender your policy to access any cash value you've built up. However, your beneficiaries would no longer receive a death benefit.

Other loan types : Finally, you can apply for other loans, such as a personal loan, that do not require life insurance as collateral. You could use loans that rely on other types of collateral, such as a home equity loan that uses your home equity.

What Are the Benefits of Collateral Assignment of Life Insurance?

A collateral assignment of a life insurance policy may be required if you need a business loan. Lenders typically require life insurance as collateral for business loans because they guarantee repayment if the borrower dies. A policy with cash value can guarantee repayment if the borrower defaults.

What Kind of Life Insurance Can Be Used for Collateral?

You can typically use any type of life insurance policy as collateral for a business loan, depending on the lender's requirements. A permanent life insurance policy with a cash value allows the lender a source of funds to use if the borrower defaults. Some lenders may not accept term life insurance policies, which have no cash value. The lender will typically require the death benefit be a certain amount, depending on your loan size.

Is Collateral Assignment of Life Insurance Irrevocable?

A collateral assignment of life insurance is irrevocable. So, the policyholder may not use the cash value of a life insurance policy dedicated toward collateral for a loan until that loan has been repaid.

What is the Difference Between an Assignment and a Collateral Assignment?

With an absolute assignment , the entire ownership of the policy would be transferred to the assignee, or the lender. Then, the lender would be entitled to the full death benefit. With a collateral assignment, the lender is only entitled to the balance of the outstanding loan.

The Bottom Line

If you are applying for life insurance to secure your own business loan, remember you do not need to make the lender the beneficiary. Instead you can use a collateral assignment. Consult a financial advisor or insurance broker who can walk you through the process and explain its pros and cons as they apply to your situation.

Progressive. " Collateral Assignment of Life Insurance ."

Fidelity Life. " What Is a Collateral Assignment of a Life Insurance Policy? "

Kansas Legislative Research Department. " Collateral Assignment of Life Insurance Proceeds ."

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Out-of-Network Billing Tips for PTs, OTs, and SLPs

Want to know how to bill insurance carriers while out of network? Check out this article.

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In the billing world, commercial payers have a lot of power. They set their own billing rules and guidelines; they choose how much they’ll pay providers; and they are under no obligation to unify their billing processes with other payers. When it comes to in-network billing, sometimes the game feels a little rigged. So, what happens when rehab therapists decide they don’t want to play ball? What options do they have? Well, it turns out they have a few. Enter the world of out-of-network billing. 

What is out-of-networking billing?

Before we talk about out-of-network billing, let’s back up and touch on what it means to be in-network. When you are in-network with an insurance company, that means you’ve been vetted and credentialed by—and signed a contract with—that particular payer. If a patient covered by the payer seeks care from you, then you’re bound by the stipulations of your contract; you must adhere to the payer’s treatment guidelines and accept its payment rates. In return, covered patients pay less for their care. 

If you’re out-of-network with a payer, you’re not contracted with it—and you may not be credentialed, either. That means you’re not bound by any of the payer’s rules, and you can choose to: 

• bill the patient directly (i.e., collect cash ); or 
• bill the payer on a patient’s behalf for what you consider fair payment. 

Collecting Payments

While you can set your out-of-network prices as you see fit, payers tend to foot less of the bill for out-of-network care, often saddling patients with large service charges. ( Depending on the patient’s coverage —HMO versus EPO, for example—the carrier may even decline to pay altogether.) So, while you can avoid rock-bottom contract rates as an out-of-network provider, your higher prices may scare away patients.

How do I bill out-of-network? 

Before billing out-of-network, you must first decide (either on a case-by-case or clinic-wide basis), whether you want to accept or decline assignment. I hear you—you’re asking, “What the heck does it mean to accept assignment?” Well, it usually means that you’re playing ball with payers—even though you’re not an in-network provider. When you accept assignment, you’re indicating that: 

• the patient’s case belongs to you and you should receive payments from the patient’s payer, and 
• you “[accept] the payer's rate for the services rendered, even if it is lower than your CPT Fee Schedule.”

On the other hand, if you decline assignment, the payer will not pay you. You may still end up billing the payer on the patient’s behalf—but you will collect all of your payments directly from the patient. 

Accepting Assignment 

If you choose to accept assignment, then you’ll fill out a claim form to send to the payer on the patient’s behalf indicating as such. (If you’re manually filling out a CMS-1500 , mark “YES” in box 27). Then, you can either:

• collect a fee from the patient at the time of service and wait for the payer to cover the rest of your bill, or
• bill the payer first and then send a statement to the patient for the remaining balance.

Both methods have their pros and cons. On the one hand, if you collect a fee from patients at the time of service, you may run the risk of overcharging them. And when patients make overpayments, you must pay them back —a very costly error. On the other hand, if a payer first reimburses you—and then you send the patient a statement for their remaining balance—then you’re doing something called balance billing. Some states have legally restricted balance billing, so be sure to brush up on your state laws before using this method. 

Declining Assignment 

If you choose to decline assignment, you have two avenues for monetary recompense. First, you can bill the insurance company on behalf of the patient. But this time, you would indicate on the claim that you’re not accepting assignment. If you choose to do this, then collect your full fee from the patient at the time of service. If the carrier does pay part of the bill, then it’ll send that payment directly to the patient. 

Alternatively, you can create a superbill for the patient and collect your full fee upfront. The patient is then responsible for seeking reimbursement from the payer. 

Accepting Payment 

As a note, please remember that all commercial payers have their own unique rules. Some payers, for instance, will mail payments directly to the patient if you are out-of-network—whether or not you accepted assignment. When you check your patients’ benefits, be sure to verify these rules with the payer. 

How do I prepare patients for out-of-network billing?

Out-of-network visits are, as a rule, almost always more expensive for patients than in-network visits. That doesn’t necessarily mean that patients won’t be willing to spend more money—but you should prepare them for that possibility. The fewer surprises for the patient, the better.

Communicating Openly Embrace communication best practices. You want to ensure that the patient is fully informed and prepared to see an out-of-network bill. Before you schedule the patient, confirm that the patient knows you’re out-of-network. There’s always a small chance that patients think you’re contracted with their insurer, and this will help you (and those patients) sidestep an uncomfortable situation. Additionally, if you can, verify each patient’s benefits before that patient’s first appointment, and communicate that status—along with the cash price of your services—so the patient has a rough idea of what the visit will cost. Keep in mind that not all payers offer out-of-network benefits; if that’s the case for your patients, they’ll want to know!

It’s also best practice to avoid telling patients that you’ll waive fees or offering them forgiveness on their bills. This sets a poor financial precedent for your practice—and it could land you in some legal hot water , to boot. 

Finally, clearly communicate the billing process you intend to follow with the patient. Patients need to know if they’re responsible for billing their insurance company—or if they simply need to watch for a bill. And for those who will receive a bill, let them know who it’s coming from. 

Are out-of-network rates better than in-network rates?

When billing payers out-of-network, providers can sometimes get more money out of them than they would under contract. Usually, a payer will reimburse an uncontracted provider with “the usual, customary, and reasonable amount” (UCR) for the provided service in that locality. But, the UCR is not ironclad; an uncontracted provider can negotiate with payers by showing them data that proves the UCR is too low. 

Does any of this apply to Medicare?

When it comes to out-of-network billing, our federal healthcare program has its own unique set of rules—especially for rehab therapists. PTs, OTs, and SLPs cannot fully opt out of Medicare like they can with commercial payers, and while they do not have to accept assignment from this federal payer, they are still contractually bound to follow its rules (e.g., charging within limit). ( Learn more here !)

The billing game might feel a little rigged, but therapists can still learn to come out on top. Out-of-network billing can totally change the game—especially for therapists who need to combat declining reimbursements.

Have questions about out-of-network billing? Feel free to drop them below. 

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Billing Non-Assigned – Frequently Asked Questions – Part 3

AMARILLO, TX – The DME industry, as we know it today, has been around for about 40 years. It is a young industry. For the first 30 years of its existence, there was little government oversight on the DME industry. This has changed. Over the last 10 years, it feels like the government is making up for lost time.

For the last four decades, suppliers have primarily provided DME on an assigned basis. Medicare paid the suppliers directly and the patients only had to pay their copayments and deductibles. Until the last several years, this worked out for DME suppliers. Until the last several years, reimbursement was high enough and audits were not onerous…..meaning that the “assignment model” worked well for suppliers. Under this “assignment model,” on the relatively rare occasion when a supplier did bill non-assigned and Medicare was asked to reimburse the patient, such reimbursement was usually made. All of this is changing.

It is becoming cost-prohibitive for many suppliers to continue with the “assignment model.” Up to now, DME supplies have shouldered the burden of the increasingly onerous Medicare policies. The suppliers have shielded their patients from the pain inflicted by Medicare policies. Financially, most DME suppliers can no longer do this. The industry is having to shift the burden (of complying with the increasingly onerous Medicare policies) to the DME suppliers’ patients. While this may be unnerving, it is the “new normal.”

What we are now witnessing are (i) DME suppliers are electing to be non-participating and (ii) DME suppliers are billing non-assigned. If a non-participating supplier provides a product on a non-assigned basis, this means that the supplier is not agreeing to accept the Medicare allowable as payment in full, can collect directly from the patient, and can charge more than the Medicare allowable in such cases. The supplier must file the claim with Medicare on behalf of the patient and any Medicare reimbursement will go directly to the patient. The bottom line is that the non-participating supplier (that is not a competitive bid contract supplier taking care of competitive bid patients) can collect up-front from the patient (i.e., bill non-assigned). But as is often the case, the “devil is in the details.”

And so let’s talk about the “details.” Set out below is Part 3 of a 3 Part series that discusses frequently asked questions (“FAQs”) pertaining to billing non-assigned.

ABNs/Medicare Advantage Question – Do ABNs apply to Medicare Advantage plans? Answer – ABNs are specific to Medicare FFS.  Whether a Medicare Advantage plan requires an ABN or something equivalent to an ABN, to hold the patient responsible if the plan denies coverage for the claim, is dependent on the particular plan.

Collection of Capped Rental Items Up Front Question – If we are billing a non-assigned capped rental item, can we collect all 13 months at the time of initial set up? Answer – No.

Medical Assistance Secondary Question – Are we allowed to bill non-assigned for patients with medical assistance secondary? Answer – This is a state by state issue. Some states allow suppliers to bill patients as long as they do not bill the Medicaid program. If the patient is a QMB Medicaid eligible, a supplier must take assignment. Other Medicaid programs may allow a supplier to not take assignment.

Prior Authorization Question – Can we bill non-assigned for items that require prior authorization through Medicare? If so, must we obtain the prior authorization? Would obtaining the prior authorization mean we must accept assignment? Answer – Yes, you can bill non-assigned on an item that requires prior approval.  Obtaining prior approval does not mean you have to take assignment.   A supplier is required to follow Medicare guidelines for coverage regardless of assignment of claim.

Avoiding Discrimination Question – Can I put in a policy across the board that I will only be selling nebulizers, rollators, etc. on a cash basis? Answer – As long as any policy is applied to patients of all payors, it should not be considered to be discriminatory.  However, Medicare enrolled suppliers should not adopt an across the board policy to only sell capped rental items.

Separate “Retail” Company Question – If we were to start a “retail” company with no PTAN or billing of insurance whatsoever, would we be allowed to sell items such as CPAP machines that are “Rx” only items? If so, would we be required to maintain charts or records of patients so we can prove we received an Rx prior to dispensing? Answer – Items that require a prescription prior to dispensing should be labeled as such.  Any item labeled as a prescription device or supply requires a prescription prior to dispensing, regardless of whether it is being sold by a Medicare supplier, “retail” company or online company with no PTAN. State licensing requirements govern who can/cannot sell Rx items. The seller of a prescription-only item should retain the Rx in its records.

Electronic Signature Question – Will Medicare accept an electronic signature from a patient for monthly rentals? Answer – Medicare should accept an electronic signature that meets the requirements of the Uniform Electronic Transactions Act (“UETA”). In the past, CMS has taken the approach that electronic signatures are not sufficient for AOBs and have attempted to require blue ink documents. We believe that as long as the UETA is followed, CMS should be required to accept electronic documentation. However, you should be aware that there is some risk that CMS may still question the use of an electronic signature. This question is being posed to CMS for clarification.

Accepting Lesser Amount From Non-Assigned Patient Question – If we usually charge all insurances (for example) $400/month for E1390, but are unwilling to accept Medicare’s rates and charge a patient $200/month as non-assigned, are we essentially saying that we would take $200/month? Would we be obligated to changing our E1390 price to $200/month?   Answer – Yes, by charging a non-assigned price of $200/month, you are stating that you will accept $200/month as adequate payment.  The price you charge for a non-assigned claim should be your usual charge, and not a reduced amount, as other payers could claim you are charging them an excess amount.

Purchase of Capped Rental Item Question – Can a non-CB supplier have the non-CB patient pay a purchase price for a capped rental item and then bill Medicare as a rental non-assigned? Answer – No, if the supplier sells the equipment as a purchase to the patient, it cannot bill Medicare as a non-assigned capped rental.

Billing After 36th Month Question – How much can a supplier bill for oxygen after the 36 months? Answer – A supplier cannot bill any amount, either to Medicare or the patient, for rental of oxygen equipment beyond the 36th month.  After the 36th month rental, the supplier can only bill for oxygen contents (if applicable), and maintenance and servicing (if performed).

Medicare Remittance Notice Question – When we bill unassigned to Medicare, will we still get the Medicare Remittance Notice or will that only go to the patient? Answer – Both the supplier and the patient will receive a copy of the remittance.  

Subsequent Denial of Non-Assigned Claim Question – If Medicare initially pays and then subsequently denies the non-assigned claim, is the supplier going to get a charge back or will the patient be asked to pay it back? Answer – If the claim is denied in a post-pay audit and the supplier did not have a signed ABN for the reason of the denial, then the supplier will have to refund the amounts collected from patient.

Question – If a supplier sells a product non-assigned, what are the reasons that Medicare can subsequently deny the claim? The supplier (not the beneficiary) will be held financially responsible and will need to refund to the beneficiary the amount the beneficiary paid.   Answer – Applicable reasons for denial requiring an ABN are denials for lack of medical necessity, failure to have a Medicare supplier number, violation of telephone solicitation prohibition, denial of an Advanced Determination of Medicare Coverage (ADMC) request, and non-contracted suppliers for competitive bid items in a CBA.

Medicare and BCBS Patients Treated the Same? Question – If you sell a nebulizer for a $75.00 cash price to a Medicare patient, do you have to do the same with a BCBS patient? Answer – No, but if you are contracted with BCBS you need to follow your contract provisions which may not allow you to sell to a BCBS patient privately.

AOB Question – If you have an AOB on file, would you still need the beneficiary to sign an authorization for every month of a non-assigned capped rental claim? Answer – Yes.  An AOB is when the supplier is accepting assignment.

Billing Secondary Insurance Question – Is the supplier on a non-assigned claim responsible to bill the beneficiary’s secondary insurance? Answer – No, a supplier is not required to bill secondary insurance on a non-assigned claim.

Response to Appeal Question – When we bill non-assigned with the coverage criteria met and the remittance shows a denial on the claim, who is responsible to appeal for payment? Answer – According to CGS, either the patient or the supplier can file the appeal.

ABN Question – If we have a Medicare customer walk in with all the medical documentation and the diagnosis qualifies for an item (walker) but Medicare allowable is low and we do not want to accept assignment, what reason do we state on the ABN for not accepting assignment? Answer – An ABN is not required for a non-assigned claim unless the supplier has a reasonable basis to believe that Medicare will deny the claim.

Notification of Billing Non-Assigned Question – Does a non-participating supplier need to post a notice that it is changing its policy on collecting upfront? Answer – A non-participating supplier can choose to not accept assignment on a claim-by-claim basis. The suppliers will likely continue to accept assignment on some items, and not on others. Therefore, the supplier should notify the patient in advance any time it will not accept assignment for an item.

CPAP Supplies Question – We are hearing from beneficiaries that they can buy CPAPs from internet sites. In this scenario, how will Medicare pay for future supplies? Answer – The patient would need to meet all Medicare requirements for the CPAP unit and the supplier would need all of this documentation to get paid for the supplies. The supplier could enter a NTE segment indicating that the patient owns the CPAP, the claim would likely deny, and would need to be reopened or appealed in order to get paid.

Exiting the Medicare Business Question – If we want to get out of the Medicare business completely, can we continue to service the rental patients we have now and just stop taking new patients? Answer – Yes, you can. However, you are required to continue servicing capped rental patients until the end of the capped rental period, or end of the 5 year period for oxygen patients. Failure to do so can be seen as violation of Medicare requirements. The same response applies whether you are participating or non-participating. You can continue servicing capped rental patients as required, but stop taking any new Medicare patients.

TPA Prohibition Against Billing Non-Assigned Question – I have a contract with a third party administrator to supply DME for its patients but I must accept assignment.  May I still be able to bill non-assigned claims to Medicare for the same equipment? Answer – You will not be discriminating against a Medicare patient so long as you only make that product available to patients for whom you are paid a threshold price, whether that payment amount is collected from the patient on a non-assigned claim, or from the payor (with patient co-pay) for an assigned claim.

Complying With Medicare Guidelines Question – If we choose to provide certain items non-assigned to Medicare beneficiaries with an ABN, is there still an expectation that an attempt to meet Medicare guidelines was made? Answer – The supplier should attempt to make sure Medicare guidelines are met for any product dispensed to a Medicare patient, whether assigned or non-assigned.  If the supplier is aware that Medicare guidelines are not met, then the supplier should have the patient sign an ABN detailing what Medicare requirements are not met as the basis for an expected denial of coverage.

Department of Hospital Question – Can a DME supplier that is a department of a participating hospital become a non-participating provider if the supplier uses the same Tax ID as the hospital?   Answer – The NSC states that if the supplier and the hospital are under the same Tax ID number, and if the hospital is participating, then the supplier must be participating as well.

CB Contract Supplier Question – Can a CB winner deny service(s)?  Rumor has it that some suppliers are not wanting to dispense walkers. Answer – A contracted winner cannot refuse to provide services for which it is contracted. If a complaint is filed with CMS, it will follow-up with the contracted supplier.

Commercial Insurance Prohibition Against Billing Non-Assigned Question – We contract with a lot of commercial insurances that prohibit billing non-assigned and that do not reimburse what we would consider to be acceptable reimbursement. Using an example of procedure code A7036, can we state that we can provide this item for a reimbursement of at or above $36? If a particular insurance company does not meet this reimbursement, we would either bill unassigned or not provide the service? Answer – You will not be discriminating against a Medicare patient so long as you only make that product available to patients for whom you are paid the threshold price set, whether that payment amount is collected from the patient on a non-assigned claim, or from the payor (with patient co-pay) for assigned claims.  In the circumstance that a commercial payor requires that you accept assignment, you can decline to make a particular product available unless the reimbursement meets the threshold amount established for that item (unless your contract requires otherwise).  

Jeffrey S. Baird , JD, is Chairman of the Health Care Group at Brown & Fortunato, PC, a law firm based in Amarillo, Tex. He represents pharmacies, infusion companies, HME companies and other health care providers throughout the United States. Mr. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization, and can be reached at (806) 345-6320 or [email protected].

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What Is Medicare Assignment?

There are many terms and acronyms when you start learning about Medicare, and “Medicare assignment” is one that may come up for you.

If you don’t find a doctor that accepts Medicare assignment, your costs for medical care could be higher, even with a Medicare Supplement. Here’s what you need to know about Medicare assignment and non-participating providers.

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What does Medicare assignment mean?

Have you ever noticed on an Explanation of Benefits that the price a doctor charges is not what you actually end up paying?

For example, your doctor may charge $350 for an office visit, but the insurance company may re-price that to $95. When the doctor decided to accept this insurance, they agreed to accept the lower payment amount.

Medicare does the same thing.  

Every year, Medicare sets the amounts they’ll agree to pay for covered services. If a doctor, provider, or supplier accepts “assignment,” it means they agree to accept the Medicare-approved amount as full payment for covered services.

What does it mean when a doctor does not accept Medicare assignment?

Any provider that doesn’t sign an agreement to accept assignment for all Medicare-covered services is called a non-participating provider .

These providers can still choose to accept assignment for individual services. As an example, a provider may accept Medicare assignment for a preventative office visit, but not for a diagnostic office visit.  

In these situations, a non-participating provider is allowed to charge you more than the Medicare-approved amount. However, there’s a limit called a “limiting charge” or “excess charge.” The provider is only allowed to charge up to 15% over the Medicare-approved amount.

If a provider chooses to completely opt-out of Medicare, that means they don’t want to work with the Medicare program at all. In these cases, you’d be paying out of pocket for any services you receive, except in the case of an emergency.

What if I have a Medicare Supplement?

If you have a Medicare Supplement, you are still allowed to see non-participating providers . Plus, if you have a Plan F or Plan G, the potential limiting charge – or excess charge – is covered by your supplemental plan.

If you have a Plan N, you would be responsible for that excess charge, which is up to 15% over the Medicare-approved amount.

For all individuals with a Medicare Supplement, you’ll want to avoid seeing providers who have opted out of Medicare. If you do see a provider who has opted out, you’d be responsible for all medical bills unless it’s an emergency.  

How do I know if my doctor accepts Medicare assignment?

Most doctors accept Medicare assignment , so rest easy! It’s pretty rare to come across a doctor that doesn’t accept Medicare.

However, finding out is easy: just ask. Plus, if a provider does not accept Medicare, they are required to have you sign a form stating that you understand this.

Finally, you can use Medicare’s Care Compare tool to double-check if your provider, doctor, or supplier accepts Medicare. We still recommend double-checking with a quick phone call, though.

What percentage of doctors accept Medicare assignment?

Depending on which source you use, anywhere from 93-99% of physicians accept Medicare assignment . If you’re going to run into a provider that doesn’t accept Medicare assignment, they’re most likely to be a specialist, such as a psychiatrist or neurologist ( Kaiser Family Foundation report ).

In general, dealing with a non-participating provider or a provider who has completely opted out of Medicare will be rare .

However, if you do run into this situation or want extra help, don’t hesitate to reach out to our office at 217-423-8000. Our licensed insurance agents can assist you with your questions.

There’s always something new to learn about Medicare! If you ever come across the term “Medicare assignment,” we hope this article helps clear things up.

As always, you do not need to learn everything about the confusing Medicare program. Please remember you can lean on our team of Medicare experts to help answer your questions and clear up the complexities.

We read the fine print so you don’t have to.

More Related Reading

• Medicare & Telehealth in Decatur, Illinois
• If You Don’t Understand Medicare At All, Start Here
• Medicare Supplement Plan G – Our Most Popular Plan

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Assignment of Benefits for Contractors: Pros & Cons of Accepting an AOB

22 articles

Insurance , Restoration , Slow Payment

When a property owner files an insurance claim to cover a restoration or roofing project, the owner typically deals directly with the insurance company. They may not have the funds available to pay the contractor out of pocket, so they’re counting on that insurance check to cover the construction costs.

But insurance companies often drag their feet, and payments can take even longer than normal. Contractors often wish they could simply deal with the insurance company directly through an assignment of benefits. In some circumstances, an AOB can be an effective tool that helps contractors collect payment faster — but is it worth it?

In this article, we’ll explain what an assignment of benefits is, and how the process works. More importantly, we’ll look at the pros and cons for restoration and roofing contractors to help you decide if an AOB is worth it . 

What is an assignment of benefits? 

An assignment of benefits , or AOB, is an agreement to transfer insurance claim rights to a third party. It gives the assignee authority to file and negotiate a claim directly with the insurance company, without involvement from the property owner. 

An AOB also allows the insurer to pay the contractor directly instead of funneling funds through the customer. AOBs take the homeowner out of the claims equation.

Here’s an example: A property owner’s roof is damaged in a hurricane. The owner contacts a restoration company to repair the damage, and signs an AOB to transfer their insurance rights to the contractor. The contractor, now the assignee, negotiates the claim directly with the insurance company. The insurer will pay the claim by issuing a check for the repairs directly to the restoration contractor. 

Setting up an AOB

A property owner and contractor can set up an assignment of benefits in two steps: 

• The owner and the contractor sign an AOB agreement
• The contractor sends the AOB to the insurance company

Keep in mind that many states have their own laws about what the agreement can or should include .

For example, Florida’s assignment of benefits law contains relatively strict requirements when it comes to an assignment of benefits: 

• The AOB agreements need to be in writing. The agreement must contain a bolded disclosure notifying the customer that they are relinquishing certain rights under the homeowners policy. You can’t charge administrative fees or penalties if a homeowner decides to cancel the AOB. 
• The AOB must include an itemized, per-unit breakdown of the work you plan to do. The services can only involve how you plan to make repairs or restore the home’s damage or protect the property from any further harm. A copy must be provided to the insurance company. 
• A homeowner can rescind an AOB agreement within 14 days of signing, or within 30 days if no work has begun and no start date was listed for the work. If a start date is listed, the 30-day rule still applies if substantial progress has not been made on the job. 

Before signing an AOB agreement, make sure you understand the property owner’s insurance policy, and whether the project is likely to be covered.

Learn more: Navigating an insurance claim on a restoration project

Pros & cons for contractors

It’s smart to do a cost-benefit analysis on the practice of accepting AOBs. Listing pros and cons can help you make a logical assessment before deciding either way. 

Pro: Hiring a public adjuster

An insurance carrier’s claims adjuster will inspect property damage and arrive at a dollar figure calculated to cover the cost of repairs. Often, you might feel this adjuster may have overlooked some details that should factor into the estimate. 

If you encounter pushback from the insurer under these circumstances, a licensed, public adjuster may be warranted. These appraisers work for the homeowner, whose best interests you now represent as a result of the AOB. A public adjuster could help win the battle to complete the repairs properly. 

Pro: More control over payment

You may sink a considerable amount of time into preparing an estimate for a customer. You may even get green-lighted to order materials and get started. Once the ball starts rolling, you wouldn’t want a customer to back out on the deal. 

Klark Brown , Co-founder of The Alliance of Independent Restorers, concedes this might be one of the very situations in which an AOB construction agreement might help a contractor. “An AOB helps make sure the homeowner doesn’t take the insurance money and run,” says Brown.  

Pro: Build a better relationship with the homeowner

A homeowner suffers a substantial loss and it’s easy to understand why push and pull with an insurance company might be the last thing they want to undertake. They may desire to have another party act on their behalf. 

As an AOB recipient, the claims ball is now in your court. By taking some of the weight off a customer’s shoulders during a difficult period, it could help build good faith and further the relationship you strive to build with that client. 

Learn more : 8 Ways for Contractors to Build Trust With a Homeowner

Con: It confuses payment responsibilities

Even if you accept an AOB, the property owner still generally bears responsibility for making payment. If the insurance company is dragging their feet, a restoration contractor can still likely file a mechanics lien on the property .

A homeowner may think that by signing away their right to an insurance claim, they are also signing away their responsibility to pay for the restoration work. This typically isn’t true, and this expectation could set you up for a more contentious dispute down the line if there is a problem with the insurance claim. 

Con: Tighter margins

Insurance companies will want repairs made at the lowest cost possible. Just like you, carriers run a business and need to cut costs while boosting revenue. 

While some restoration contractors work directly with insurers and could get a steady stream of work from them, Brown emphasizes that you may be sacrificing your own margins. “Expect to accept work for less money than you’d charge independently,” he adds. 

The takeaway here suggests that any contractor accepting an AOB could subject themselves to the same bare-boned profit margins. 

Con: More administrative work

Among others, creating additional administrative busywork is another reason Brown recommends that you steer clear of accepting AOBs. You’re committing additional resources while agreeing to work for less money. 

“Administrative costs are a burden,” Brown states. Insurers may reduce and/or delay payments to help their own bottom lines. “Insurers will play the float with reserves and claims funds,” he added. So, AOBs can be detrimental to your business if you’re spending more while chasing payments. 

Con: Increase in average collection period

Every contractor should use some financial metrics to help gauge the health of the business . The average collection period for receivables measures the average time it takes you to get paid on your open accounts. 

Insurance companies aren’t known for paying claims quickly. If you do restoration work without accepting an AOB, you can often take action with the homeowner to get paid faster. When you’re depending on an insurance company to make your payment, rather than the owner, collection times will likely increase.

The literal and figurative bottom line is: If accepting assignment of benefits agreements increases the time it takes to get paid and costs you more in operational expense, these are both situations you want to avoid. 

Learn more: How to calculate your collection effectiveness 

AOBs and mechanics liens

A mechanics lien is hands down a contractor’s most effective tool to ensure they get paid for their work. Many types of restoration services are protected under lien laws in most states. But what happens to lien rights when a contractor accepts an assignment of benefits? 

An AOB generally won’t affect a contractor’s ability to file a mechanics lien on the property if they don’t receive payment. The homeowner is typically still responsible to pay for the improvements. This is especially true if the contract involves work that wasn’t covered by the insurance policy. 

However, make sure you know the laws in the state where your project is located. For example, Florida’s assignment of benefits law, perhaps the most restrictive in the country, appears to prohibit an AOB assignee from filing a lien. 

Florida AOB agreements are required to include language that waives the contractor’s rights to collect payment from the owner. The required statement takes it even further, stating that neither the contractor or any of their subs can file a mechanics lien on the owner’s property. 

On his website , Florida’s CFO says: “The third-party assignee and its subcontractors may not collect, or attempt to collect money from you, maintain any action of law against you, file a lien against your property or report you to a credit reporting agency.”

That sounds like a contractor assignee can’t file a lien if they aren’t paid . But, according to construction lawyer Alex Benarroche , it’s not so cut-and-dry.

“Florida’s AOB law has yet to be tested in court, and it’s possible that the no-lien provision would be invalid,” says Benarroche. “This is because Florida also prohibits no-lien clauses in a contract. It is not legal for a contractor to waive their right to file a lien via an agreement prior to performance.” 

Learn more about no-lien clauses and their enforceability state-by-state

Remember that every state treats AOBs differently, and conflicting laws can create additional risk. It’s important to consult with a construction lawyer in the project’s state before accepting an assignment of benefits. 

Best practices for contractors 

At the end of the day, there are advantages and disadvantages to accepting an assignment of benefits. While it’s possible in some circumstances that an AOB could help a contractor get paid faster, there are lots of other payment tools that are more effective and require less administrative costs. An AOB should never be the first option on the table . 

If you do decide to become an assignee to the property owner’s claim benefits, make sure you do your homework beforehand and adopt some best practices to effectively manage the assignment of benefits process. You’ll need to keep on top of the administrative details involved in drafting AOBs and schedule work in a timely manner to stay in compliance with the conditions of the agreement. 

Make sure you understand all the nuances of how insurance works when there’s a claim . You need to understand the owner’s policy and what it covers. Home insurance policy forms are basically standardized for easy comparisons in each state, so what you see with one company is what you get with all carriers. 

Since you’re now the point of contact for the insurance company, expect more phone calls and emails from both clients and the insurer . You’ll need to have a strategy to efficiently handle ramped-up communications since the frequency will increase. Keep homeowners and claims reps in the loop so you can build customer relationships and hopefully get paid faster by the insurer for your work.

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Insurance Assignment

Insurance Assignment Explanation: Insurance Assignment Insurance assignment allows insured patients to authorize their dental benefits plan carrier to pay your office directly for covered services. It is then your responsibility to collect any remaining amount owed by the patient. If you choose to take assignment, ABELDent will keep track of amounts owed by the patient, and by the patient’s insurance carrier separately. This way, a patient will only be billed for those amounts not covered under their insurance. Many offices use insurance assignment to make treatment costs more affordable for patients who have insurance coverage.

Levels of Assignment in ABELDent To provide you with flexibility in managing assignment, ABELDent offers three levels of assignment— System level, Insurance Plan level and Patient level. •   System : Use this level if you plan to take any type of assignment. When you select this option, ABELDent will create and track two Account Receivables—one for insurance and one for patients. To activate, select the  Assignment in System  option in  System Setup.  •   Insurance Plan : Use this level to take assignments for specific insurance plans. To activate, select the  Take Assignment  option when adding or editing  a patient’s insurance plans. Important:  We recommend that you always choose  assignment at the insurance plan level. This doesn’t mean you have to take assignment, but if you decide to take assignments for patients you can do so without having to return and set up the insurance plan assignment. •   Patient:  Use this level to take assignments for  individual patients. To activate, select the  Take Assignment?  option on the patient’s Insurance tab when assigning plans to the patient’s record.

What are the Billing Options? If your office decides to take insurance assignment, you can bill using either of the following methods: •  Bill the entire cost of a procedure to the patient’s insurance company. Upon receiving the insurance payment portion (either through the mail, or from an EOB received via EDI transmission of the treatment cost (e.g. 80%), you can bill the patient for the remainder, or uninsured portion of the cost. •  Bill the patient portion of the procedure immediately and receive the insurance portion later. Enter the patient’s insurance plan coverage (including maximums, deductibles, and percentage of coverage for Preventive, Basic, Major, and Ortho). ABELDent will automatically separate what the patient owes from what the insurance is covering, allowing the patient to pay what they owe immediately.

Should I Use Insurance Assignment? Whether or not to accept assignment of benefits is a decision that each practice should make individually.   ABELDent simply provides features that make the administration of assignment easier for those offices that decide to use them. Offices may make the decision to accept assignment based on such non-computer factors as: •  Practice’s philosophy on responsibility for payment •  Marketing and competitive pressures •  Ability of the staff to collect from patients •  Economic health of the patients in the practice

Insurance Assignment and CDAnet Your practice can submit claims electronically using CDAnet whether or not you accept insurance assignment for your patients. The assignment status of each insurance claim is automatically determined from your data when treatment is entered, and sent with the electronic claim electronically to the insurance carrier. References: Product (s): ABELDent Category: Insurance Classification: Public Date Created: 04 September 2015 Created by: Brian Neale  

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What does it mean to accept assignment on an insurance claim?

Table of Contents

• 1 What does it mean to accept assignment on an insurance claim?
• 2 What does not accepting assignment mean?
• 3 What does it mean to accept a claim?
• 4 When a claim is paid by assignment this means that the payment goes directly to the?
• 5 What information does RTA allow practice to view?
• 6 Why do doctors stop accepting insurance?
• 7 What is accepting assignment in insurance?
• 8 What does assignment mean in Medicare?

If you tell someone that you accept assignment it means that you will accept the insurance company ALLOWED amount as payment in full. So if the insurance company does not reimburse you their entire ALLOWED amount you can bill the patient for the difference between the allowed amount and the payment.

What does accept assignment mean on CMS 1500?

If the provider accepts assignment, the Medicare payment will be made directly to the provider. Under this method, the provider agrees to accept the Medicare approved amount as full payment for covered services.

What does not accepting assignment mean?

A: If your doctor doesn’t “accept assignment,” (ie, is a non-participating provider) it means he or she might see Medicare patients and accept Medicare reimbursement as partial payment, but wants to be paid more than the amount that Medicare is willing to pay.

When accept assignment is checked yes in the claim form it indicates that?

YES means that payment should go directly to you instead of the patient. Generally speaking, even if you have an assignment of benefits from the patient (see box 12 & 13), payment is ONLY guaranteed to go to you IF you accept assignment.

What does it mean to accept a claim?

Accepted claim, or admitted claim, is a workers’ compensation claim that your employer’s insurance company accepts as being covered by worker’s compensation. When you have an accident or illness that is work related, in order to get workers’ compensation benefits, you have to file a workers’ compensation claim.

What happens if my doctor doesn’t accept my insurance?

Contact your insurance company “Call them and state your case. Sometimes they’ll honor your appeal. If the issue is the doctor wanting cash or not wanting to deal with the insurance company, however, you may need to either pay up or move on,” suggests Martin.

When a claim is paid by assignment this means that the payment goes directly to the?

Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. These providers are required to submit a bill (file a claim) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care.

What does accepting assignment mean with Medicare?

Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.

What information does RTA allow practice to view?

What information does RTA allow the practice to view? the amount the health plan will pay and amount patient will owe.

What is Article 75 decision RTA?

Article 75 is an agreement between the Motor Insurers’ Bureau (the MIB) and its members under which the motor insurer will accept liability in certain cases where they would not be liable under the Road Traffic Act 1988 (RTA 1988) (as RTA insurer).

Why do doctors stop accepting insurance?

Doctors may stop taking insurance if they believe the health insurance company isn’t offering enough compensation. If a doctor stops taking your health insurance, you have a few avenues, including asking if the doctor will take a reduced fee or provide flexible payment terms.

Which doctors accept Medicare assignment?

What is accepting assignment in insurance?

What does it mean to approve something?

What does assignment mean in Medicare?

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