Charges for Medicare-Eligible Patients with a Primary Commercial InsuranceWe have become increasingly accustomed to the growing number of working aged people retaining commercial group health insurance as a primary insurance, and Medicare benefits as a secondary payer for health insurance. What should a physician charge if Medicare is a secondary payer? The answer is dependent on several factors. In general, for non-assigned claims, the patient should not be charged more than the New York State Limiting Charge. This is particularly important if the physician's office request payment for the services at the time of the visit. This indicates that the physician is not accepting assignment for the services reimbursed by the primary commercial carrier. The patient is protected by the Limiting Charge whether Medicare is the primary or the secondary insurance. It is important, however, to remember that physicians who have "opted out" of the Medicare program for at least two years are allowed to charge the Medicare beneficiary their usual and customary charge. The patients must be made aware that the Medicare program will not reimburse either the physician or the patient for any services received from an "opt out" physician. In addition, the Medicare program recently announced (Compass, Winter 2000) that both participating an non-participating Medicare physicians may bill patients their usual and customary charges for any and all services that are deemed non-covered by the Medicare program due to the medical diagnoses or the frequency of the service. The patient must sign a valid Advanced Beneficiary Notice (ABN) prior to the provision of the service, and the claim submitted with the modifier GA to indicate that the ABN is on file in the physician' office.
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