Article Date: 4/1/2002

Coding Q & A
Medicare Basics
It's not uncommon to see things as a little unclear when it comes to dealing with Medicare. Here are some answers to common questions.

What is Medicare's fee schedule?

Answer: Medicare pays you for covered services based on a fee schedule. The fee schedule is published and mailed in December of each year by your local Medicare carrier. This way you know in advance what Medicare expects to pay for a particular service. The fee schedule amount is commonly called the "allowable."

Medicare payment is based on its allowable or your charge, whichever amount is less.

Suppose, for example, Medicare's allowable for a service is $100, but your usual fee is $90. You would submit a claim to Medicare for your usual fee ($90) and then Medicare would pay based on that amount.

Conversely, if your usual fee for the service is $120, Medicare will pay based on the allowable of $100. You're not permitted to have a higher fee schedule for billing Medicare, so use your usual fees.

Why is my check always less than the fee schedule amount?

Answer: Medicare wants its enrollees, called beneficiaries (your patients), to purchase health care prudently. It encourages this caution by requiring patients to pay a portion of their own healthcare costs. In other words, it pays part of the allowable and expects the patient to pay the rest of the sum.

Medicare pays 80% of the allowable. The patient's share, called a "co-payment," is 20% of the allowable. Medicare patients also have an annual deductible amount -- they must pay the first $100 of covered expenses each calendar year.

Many patients have a supplemental, or secondary, insurance policy that pays the co-payment and deductible for them. Most of these secondary plans follow Medicare's rules for coverage, although some are more generous.

What is "assignment?"

Answer: Medicare pays either the patient or you (the doctor who provides the covered service). Because the insurance benefit belongs to the patient, you can't receive payment unless the patient "assigns" the benefit to you.

The patient does this one of two ways: he either signs a HCFA-1500 form (the Medicare claim form) each time you provide a service, or he signs an Assignment of Benefits form. This form is also known as a Signature-on-File form, or a Lifetime Signature form.

The form has specific, required wording (see "Sample Lifetime Signature Form"). It's obviously much more convenient for both you and the patient to use a lifetime signature form because each patient must sign it only once.

Accepting assignment on Medicare services has several very important effects. It means that:

You need to know it

Remember, you need to understand the rules to make sure you get paid what you are entitled to receive for excellent patient care.

In next month's article we'll discuss Medicare's participating physician program and what it means to your practice.



Sample Lifetime Signature Form --Assignment of BenefitsBeneficiary Name (print) Medicare Number

MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to __________, for services furnished me by __________. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration) and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. __________ accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and noncovered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.

MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to __________, if possible or otherwise to me.


Optometric Management, Issue: April 2002