Liability Insurance billing

Alternative Billing for Liability Insurance and Charges to Patients

Generally, providers, physicians and other suppliers must bill liability insurance prior to the expiration of the promptly period rather than bill Medicare. (The filing of an acceptable lien against a beneficiary’s liability insurance settlement is considered billing the liability insurance.) Promptly means payment within 120 days after the earliest of:

* The date the claim is filed with an insurer or a lien is filed against a potential liability settlement.Or,

* The date the service was furnished, or, in the case of inpatient hospital services, the date of discharge. Following expiration of the promptly period, or if demonstrated (e.g., a bill/claim that had been submitted but not paid) that liability insurance will not pay during the promptly period, a provider, physician or other supplier may either:

* Bill Medicare for payment and withdraw all claims/liens against the liability insurance/beneficiary’s liability insurance settlement (liens may be maintained for services not covered by Medicare and for Medicare deductibles and coinsurance).
Or,

* Maintain all claims/liens against the liability insurance/beneficiary’s liability insurance settlement.

Charges to Patients

Charges to Patients for Services Covered by Medicare

The following applies to providers who participate in Medicare:

If the provider bills Medicare, the provider must accept the Medicare approved amount as payment in full and may charge beneficiaries only deductibles and coinsurance.

If the provider pursues liability insurance, the provider may charge beneficiaries actual charges, up to the amount of the proceeds of the liability insurance less applicable procurement costs but may not collect payment from the beneficiary until after the proceeds of the liability insurance are available to the beneficiary.

Physicians and other suppliers who do not participate in Medicare and who submit a non-assigned claim may charge beneficiaries no more than the limiting charge and may collect without regard to whether the liability insurance is available to the beneficiary.

Physicians and other suppliers, who do not participate in Medicare, do not submit a non-assigned claim and are not required to submit an assigned claim if they submit a claim to Medicare, may pursue liability insurance but the amount may not exceed the limiting charge.

Charges to patients for Services Not Covered by Medicare

For services for which there is no Medicare coverage available regardless of who furnishes them, providers, physicians and other suppliers may charge and collect actual charges from beneficiaries without regard to whether the proceeds of the liability insurance are available to the beneficiary.

For services of foreign hospitals that have no election to bill Medicare, providers may charge and collect actual charges from beneficiaries without regard to whether the proceeds of the liability insurance are available to the beneficiary.

For services of foreign physicians and other suppliers, the physician or other supplier may charge and collect actual charges from beneficiaries without regard to whether the proceeds of the liability insurance are available to the beneficiary.

Instructions for Charging the Beneficiary

A physician or supplier who has received assigned benefits may not return the Medicare payment to the carrier and bill full charges to a beneficiary who has received a liability award or settlement. Nor may a physician or supplier who has accepted assignment but not yet received the Medicare payment decline on similar grounds to accept Medicare payment and bill the patient full charges. Under the terms of the assignment, the physician or supplier may bill only for the applicable deductible and coinsurance amounts. The beneficiary’s receipt of a liability award or settlement does not permit rescission of the assignment agreement.

The following are special circumstances:

When a no-fault plan denies some or all of a claim on the basis of benefit exhaustion or specific no-fault policy coverage exclusion applicable to alpolicyholders, Medicare may pay for the services, subject to meeting normal Medicare guidelines. A copy of the denied Explanation of Benefits (EOB) from the no-fault plan must accompany the claim to Medicare.

Primary Medicare benefits may not be paid merely because the beneficiary wants to save his automobile insurance for future benefits.

A physician or supplier who accepts assignment may not file a lien against a beneficiary’s liability insurance proceeds. To do so would be a violation of the assignment agreement.

Please also see What is Liability insurance and No-Fault Insurance? & Medicare Secondary Payer

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