(Medicare Claims Processing Manual)

In mandatory assignment situations, i.e., where payment under the Act can be made only on an assignment -related basis or where payment is for services furnished by a participating physician or supplier, the beneficiary (or the person authorized to reques t payment on the beneficiarys behalf) is not required to assign the claim to the physician or supplier in order for an assignment to be effective.  However, the beneficiary (or the person authorized to request payment on the beneficiarys behalf) must con tinue to authorize the release of medical or other information necessary to process the claim and request payment of Medicare benefits for the Medicare Part B covered services, equipment, or supplies pursuant to 42 C.F.R 424.32 and 424.36 (see also Pub. 100- 04, ch. 1, sect. 50.1).  Physicians or suppliers who agree to (or must by law) accept assignment from Medicare cannot attempt to collect more than the appropriate Medicare deductible and coinsurance amounts from the beneficiary, his/her other insurance, or anyone else.   In situations where mandatory assignment is not applicable and a nonparticipating physician or supplier indicates on the claim that he/she accepts assignment, but the beneficiary does not assign the claim to that nonparticipating physician/supplier -- payme nt must be made on an unassigned basis (i.e., directly to the beneficiary).   A violation of the assignment occurs if the physician/supplier collects (or attempts to collect) from the enrollee or anyone else any amount which, when added to the benefit, exceeds the Medicare allowed amount. A bill for assigned services is considered paid in full when the Medicare allowed amount is paid.  The carrier payment determination takes into account all of the services furnished by the physician/supplier in connection with the claim.  Therefore, a physician/supplier may not charge the enrollee f or paperwork involved in filing an assigned claim.   If the enrollee has private insurance in addition to Medicare, the physician/supplier who has accepted assignment of SMI benefits is in violation of his/her assignment agreement if he/she bills or collects from the enrollee and/or the private insurer an am ount which, when added to the Medicare benefit received, exceeds the Medicare allowed amount.  If it comes to a carriers attention that a physician/supplier has received an excessive amount, inform him/her to refund such amount to the appropriate party.  Where it is not clear as to who is entitled to receive the refund under the terms of the private insurance, any excess amount paid by the enrollee may be returned to the enrollee.   A nonparticipating physician/supplier who accepts assignment for some Medicare covered services is not ordinarily precluded from billing the patient for other Medicare covered services for which the nonparticipating physician/supplier does not accept assig nment, and is also not precluded from billing the patient for services that are not covered by Medicare.  However, a physician/supplier may not attempt to circumvent the Medicare allowed amount limitation by fragmenting his/her bills.  Bills are fragmen ted when a physician/supplier accepts assignment for some services, and claims payment from the enrollee for other services performed at the same place and on the same occasion.  When a carrier becomes aware that a physician/supplier is fragmenting his/he r bills, it must inform him/her that this practice is unacceptable and that he/she must either accept assignment for, or bill the enrollee for, all services performed at the same place and on the same occasion.   EXCEPTION:  In mandatory assignment situations, i.e., where a physician/supplier must accept assignment for certain services as a condition for any payment or for full payment to be made (e.g., clinical diagnostic laboratory tests, physician assistants), he/she may ac cept assignment for those services without accepting assignment for other services furnished by him/her for the same enrollee at the same place and on the same occasion.   30.3.3 - Physicians Right to Collect From Enrollee on Assigned Claim Submitted to Carriers  (Rev. 1, 10- 01-03) B3-3045.2  A.  Before the Claim is Submitted   The provider (including physicians and suppliers) who is accepting assignment should not attempt to collect more than 20 percent of the charge from the enrollee when the deductible has been met.  He or she should, if the occasion arises, be advised not to do so. Any greater amount collected will:  1. Reduce the amount payable to him/her on the assigned claim,   2. Cause the enrollee unnecessary hardship in raising the excess amount, and   3. Require extra work for the carrier in paying this excess to the enrollee instead of the physician.  However, a provider (including physicians and suppliers) may accept assignment after having collected a part of his/her bill.  The fact that the enrollee has paid more than any deductible and coinsurance due does not invalidate the assignment.   B.  Showing the Amount Collected on the Claims Form   In submitting an assigned claim, the provider (including physicians and suppliers) must show on Form CMS -1500 any amount he/she has collected from the enrollee for these services.  This information is essential for correct payment of the benefits due; failure to show the amount paid is likely to result in excessive benefit payment to the provider (including physicians and suppliers) (i.e., a benefit payment which, when added to the amount already paid by the enrollee, will exceed the Medicare allowed amount).  EXAMPLE:  The physician accepted assignment of a bill of $300 for covered services and collected $60 from the enrollee, but failed to show on the claim form that he/she had collected anything.  The carrier determined the Medicare allowed amount to be $250, and since the deductible had previously been met, made payment of $200 to the physician.  Since the physician would have received $190 in benefit payments and the enrollee $10 if the amount collected had been shown on the claim form, the physician has bee n overpaid $10.  When this overpayment comes to light, e.g., by a complaint from the enrollee, the carrier will take necessary corrective action, e.g., advise the physician to refund the $10 to the enrollee and if he/she fails to do so, pay the enrollee the $10 and recover the overpayment from the physician.  C.  Physician Should Not Bill Enrollee After the Claim is Submitted   After the provider (including physicians and suppliers) has accepted assignment he/she should not bill the enrollee or try to collect from him/her any additional part of the bill until he/she receives the carriers Medicare Summary Notice (MSN).  Where the provider (including physicians and suppliers) collects any substantial part of his/her bill from the enrollee after submitting his/her claim, such collection is likely to be an overcollection, and a violation of the assignment agreement.  Furthermore, the  enrollee who receives a bill from the provider (including physicians and suppliers) may submit such bill to the carrier with his/her own claim for benefits, causing confusion, possible duplicate payment, or payment of benefits to the enrollee rather than the provider (including physicians and suppliers).  EXAMPLE:  The physician accepted assignment of a bill of $300 for covered services, and collected $60 from the enrollee after the Form CMS -1500 had been filed with the carrier, but before receiving notice of the Medicare allowed amount.  The carrier determined that the Medicare allowed amount was $250, and since the Form CMS -1500 did not show any payment made by the enrollee, paid the physician $200 (80 percent of the $250 Medicare allowed amount).  The result is that the physician has overcollected from th e enrollee by $10.   When this overcollection came to light through a complaint from the enrollee, the carrier notified the physician that the $10 must be refunded to the enrollee.  Unlike the excess payment made because the physician fails to show the amount collected on the claims form (see the example in B above), this $10 does not constitute a program overpayment; the carrier should not apply recovery procedures applicable to overpayments, and should not pay the $10 to the patient unless the physician first refunds it to the carrier (in lieu of refunding it directly to the patient).   If the physician, after submitting his/her claim , collects an additional amount on his/her bill, and the carrier learns of such collection before making SMI payment, the carrier should adjust its payments to the physician and enrollee accordingly.  However, even if the physician collected the entire bil l, requiring that the full SMI benefit be paid to the enrollee, the Medicare allowed amount limitations of the assignment still apply.   D.  Durable Medical Equipment Supplier Bills for Coinsurance at the Time Claim Submitted   Notwithstanding the guideline in C above, a supplier of durable medical equipment may bill the beneficiary for 20 percent of the Medicare allowed amount at the same time it submits an assigned claim to the carrier for the items and services furnished.  The  supplier must undertake:   1. To bill the beneficiary at the time it submits the claim only for 20 percent of the Medicare allowed amount; and   2. To inform the beneficiary prominently on its invoice that:   a. It has submitted a claim to the carrier for the items and services and he/she should not him/her self submit such a claim; and  b. The bill is for 20 percent of the Medicare allowable charge and is not covered by Medicare; and   3. To establish and maintain adequate procedures for refund of any over collections from the beneficiary that might result from the carrier approving a different Medicare allowed amount than that submitted.   30.3.4 - Effect of Assignment Upon Rental or Purchase of Durable Medical Equipment on Claims Submitted to Carriers  (Rev. 1, 10- 01-03) B3-3045.3  A.  Equipment More Expensive Than Standard Item   An item of durable medical equipment may have certain convenience or luxury features that make it more expensive than a standard item, i.e., one which will adequately meet the medical needs of the patient.  The charge for the more expensive item cannot exceed the fee schedule amount for the item adequate for the patients medical needs.  Only if a more expensive item or model with special features is medically necessary for the beneficiary will the Medicare allowed amount be based on the more expensive mode l.  If the patient purchases or rents an item of durable medical equipment having more expensive features than his/her condition requires, the supplier accepting assignment on such an item cannot charge or collect any amount in excess of the Medicare allowed amou nt for the appliance adequate for the patients needs.  Acceptance of assignment binds the supplier to accept the Medicare allowed amount determined by the carrier, as the full charge for the item.  A supplier who wishes to charge and collect the full pric e for equipment more expensive than medically required by the patient need not accept assignment.  Refer to chapter 30, for advance beneficiary notice (ABN) provisions.   EXAMPLE:  An enrollee who needs a wheelchair is sold a motorized chair although a manually operated chair would meet his/her medical needs.  The Medicare allowed amount in this case is the Medicare allowed amount for a manually operated chair. Therefore, if the supplier accepts assignment, he/she cannot collect from the enrollee any amount in excess of the difference between the amounts of the SMI benefit paid to the supplier and the Medicare allowed amount for the manually- operated chair.   B.  Equipment No Longer Medically Necessary   In assignment cases, the beneficiary is responsible for paying the supplier the unpaid balance of the Medicare allowed amount when payments stop because his/her condition has changed and the equipment is no longer medically necessary.  Similarly, when paym ents stop because the beneficiary dies, his/her estate is responsible to the supplier for such unpaid balance.   NOTE: Carriers should not get involved in issues relating to ownership or title to property.   30.3.5 - Effect of Assignment Upon Purchase of Cataract Glasses From Participating Physician or Supplier on Claims Submitted to Carriers  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A pair of cataract glasses is comprised of two distinct products:  a professional product (the prescribed lenses) and a retail commercial product (the frames). The frames serve not only as a holder of lenses but also as an article of personal apparel. As s uch, they are usually selected on the basis of personal taste and style.  Although Medicare will pay only for standard frames, most patients want deluxe frames. Participating physicians and suppliers cannot profitably furnish such deluxe frames unless they can make an extra (noncovered) charge for the frames even though they accept assignment.   Therefore, a participating physician or supplier (whether an ophthalmologist, optometrist, or optician) who accepts assignment on cataract glasses with deluxe frames may charge the Medicare patient the difference between his/her usual charge to private pay  patients for glasses with standard frames and his/her usual charge to such patients for glasses with deluxe frames, in addition to the applicable deductible and coinsurance on glasses with standard frames, if all of the following requirements are met:   A. The participating physician or supplier has standard frames available, offers them for sale to the patient, and issues and ABN to the patient that explains the price and other differences between standard and deluxe frames. Refer to Chapter 30.