billing question regarding "memberships"

[MightyMee]

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Hello! I am going to say first I am the owner of an insurance billing company, specializing in EMS for well over 20 yrs.

BUT, even the best of us can get confused at times. Thought maybe someone here could enlighten my brain waves and relax the hair on the back of my neck so they can lay down.

My concern is all these counties in TX having "membership fee's for the public, so there is no out of pocket money paid if insurance does not cover the whole bill. The way I understand it, if Medicare does not pay the whole allowed amount Mr. Whoever, has paid his $35.00 for the year to the county plan, so he isn't charged for co-pay, co-insurance or deductible. Am I understanding this correctly? When I called the City office who uses this plan and two county offices, they said, yes that is right. Now then, my question is: Is this not considered by them to be fraud and abuse by Medicare which does not allow the write off of co-pays, co-insurance or deductibles?

Yes, I did contact Medicare and OIG and they have agreed it sounds like it would fall under this category. Can someone let me know what I am missing, because I also see this is popping up in another state also.

Thanks in advance for your kindness. OH and no I am NOT turning any one in, that is not my point and why I didn't mention any names. I am just totally wondering myself, before I take on a client and find out I am involved.

[Just Plain Ruff]

my understanding is that once medicare pays you cannot go after the patient personally for the money not collected but you can go after their secondary insurance if they have one.

I am pretty sure why that is why we have secondary medicare insurance.

I may be wrong since it's been a while since I dealt with insurance issues.

I would get a ruling on this from medicare before you take a bigger plunge.

[scratrat]

Yes, it is fraud. How they don't get caught is beyond me. If they are not billing the pt's for co-pays, they risk losing Medicare reimbursements.

Medicare REQUIRES, read REQUIRES, they every pt be billed for their applicable co-pay, usually around $25.00, I believe. It does not, however, say that the pt is required to pay. Most squads, send the pt 3 bills, then write it off. But even after Medicare pays the bill, the pt is still responsible for the co-pay. You cannot bill the pt $300 though, and then bill Medicare for the same.

[MightyMee]

[/font:d3b7e6109a] :shock: Thank you! This is how I read it and practice it , this is what I was told by Medicare and OIG. BUT, when I asked out right of one of the companies doing this I was told, we have done this for 10 yrs and 5 counties and never had a problem!

If there is a second or third insurance yes of course it gets billed, but to promote it by telling the public (residents) they do not have to pay out of pocket anything if they join membership seemed wrong to me. Medicare has always said no waiving of co-pays etc. Other insurances, say they are in a contract legal and binding with the insured advising the insurance company pays their portion and the insured then by policy contract must pay their portion.

I was thinking maybe I missed something and there was a written exception somewhere for EMS providers. But I really didn't think so. I appreciate your help. I do not want to jeapordize my company by taking on a client that has this procedure.

May I add a note to all EMS people! May you all stay safe and be under the wings of Gods Special Guardian Angels. You people do fantastic work, and I for one could never do what you do, thank God you are available!!

[Chief1C]

I suggest speaking with an attorney that specializes in medical law and billing.

[Just Plain Ruff]

I agree with the above post, the lawyer can get you a final ruling from medicare and then you will know where you stand.

Advice from us dolt's on this site is good but nothing beats getting the information direct from the horses mouth.