Can a provider collect coinsurance based on “allowable fees” up front from a Medicare or Medicare Advantage plan before the claim is submitted? Background: I know most straight Medicare plan have a coinsurance plan which after deductible is met the medical and/or medical services will be covered at 100%. But, what about a Medicare Advantage plan? Most have 20% coinsurance with an out-of-pocket limit that must be met before benefits are covered at 100%.
I assumed that you cannot collect coinsurance before the claim was processed, but some of our peers opined otherwise. What is your answer? Can you provide sited policy from Medicare on this matter as well in your response?
ANSWERS
Medicare Advantage (MA) will be a private insurance so it is impossible to say universally what a MA Plan would allow one to do. It depends if contracted vs non-contracted provider as well, so check that private payer website.
Medicare has specific regulations on collections so these two paragraphs answer the question. This answer comes from CMS, Chapter 3 and that link: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/p151_03.zip
302.5 Deductible and Coinsurance Amounts.--Deductible and coinsurance amounts are amounts payable by beneficiaries for covered services received from providers of services, excluding medical and surgical services rendered by physicians and surgeons. These deductibles and coinsurance amounts, including the blood deductible, must relate to inpatient hospital services, post-hospital extended care services, home health services, out-patient services, and medical and other health services furnished by a provider of services.
310. REASONABLE COLLECTION EFFORT
To be considered a reasonable collection effort, a provider's effort to collect Medicare deductible and coinsurance amounts must be similar to the effort the provider puts forth to collect comparable amounts from non-Medicare patients. It must involve the issuance of a bill on or shortly after discharge or death of the beneficiary to the party responsible for the patient's personal financial obligations. It also includes other actions such as subsequent billings, collection letters and telephone calls or personal contacts with this party which constitute a genuine, rather than a token, collection effort. The provider's collection effort may include using or threatening to use court action to obtain payment. (See §312 for indigent or medically indigent patients.)