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Charges and Reimbursement When Medicare is the Secondary PayerPhysicians participating in the Medicare Program, expecting payment at the time of the service from patients with health insurance coverage from a commercial carrier may not charge the patient more than the amount of reimbursement that would have been approved by the Medicare Program. However, if payment for the services is deferred until the claim has been reimbursed by the private or commercial insurance, the charge to the commercial insurance is not restricted to the Medicare approved amount. Participating Medicare physicians should always utilize their usual and customary charges on claims to health insurance carriers. The key is that the insurance carrier may pay up to the individual fee schedule or the usual and customary charge noted on the claim, but the Medicare patient may not be charged more than the Medicare approved amount if payment is not deferred. Once the primary insurance has reimbursed the claim, the explanation of benefits from the primary insurance must be submitted to the Medicare Program for additional reimbursement. The patient may only be billed for the Medicare deductible and or coinsurance if applied to the reimbursement apportioned. Nonparticipating physicians in the Medicare program may not bill the patient directly for any amount above the "limiting charges" associated with each service. Nonparticipating Medicare physicians may bill the health insurance carriers at the usual and customary charges, but patients may not be balance billed more than the limiting charge. Limiting charges are set, in New York State, at 105% above the nonparticipating Medicare fee schedule, except fpr office visits. Physician Medicare participation status directly impacts on the amount of monies, and method of fee collection for all patients with Medicare Part B coverage, whether that coverage is primary or secondary.
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