American College of Physicians: Internal Medicine — Doctors for Adults ®

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When it's OK to bill Medicare patients

From the February 1998 ACP Observer, copyright 1998 by the American College of Physicians.

There has been a great deal of confusion over provisions of the Balanced Budget Act that regulate the issue of private contracting between physicians and Medicare enrollees. While the new law regulates the complex but separate issue of private contracting, physicians can continue to bill Medicare patients for uncovered services.

As always, physicians can bill Medicare patients for any services not covered by Medicare. This does not require a "private contract," which is regulated by the new law, and it does not require physicians to "opt out" of Medicare for two years. Examples of noncovered services include routine physical exams, hearing aids and cosmetic surgery.

Physicians may also bill a Medicare enrollee for services that Medicare covers under some circumstances but deems medically unnecessary for that particular patient. In these cases, HCFA requires that the patient sign an "advance beneficiary notice" agreeing to assume responsibility for payment. Examples of such services include multiple nursing home visits and multiple mammograms within a 12-month period. Many physicians have used this process and may continue to do so.

Neither of these provisions has been changed by the Balanced Budget Act of 1997. The new law allows physicians to make arrangements for Medicare enrollees to pay for Medicare-covered services out of their own pocket but requires those physicians to give up all Medicare claims for a two-year period.

For more details on the new law, go to ACP Online (www.acponline.org) and look for "Medicare Payment for Non-covered Services."

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