CMS Pub. 100-04, ch. 1, § 30.3.3

Submitted to Carriers

(Rev. 12511; Issued:02-15-24; Effective: 01-01-24; Implementation: 03-18-24)

A. Before the Claim is Submitted

The provider (including physicians and suppliers) who is accepting assignment should

not attempt to collect more than 20 percent of the charge from the enrollee when the

deductible has been met. He or she should, if the occasion arises, be advised not to do so.

Any greater amount collected will:

1. Reduce the amount payable to him/her on the assigned claim,

2. Cause the enrollee unnecessary hardship in raising the excess amount, and

3. Require extra work for the carrier in paying this excess to the enrollee instead of

the physician.

However, a provider (including physicians and suppliers) may accept assignment after

having collected a part of his/her bill. The fact that the enrollee has paid more than any

deductible and coinsurance due does not invalidate the assignment.

B. Showing the Amount Collected on the Claims Form

In submitting an assigned claim, the provider (including physicians and suppliers) must

show on Form CMS-1500 any amount he/she has collected from the enrollee for these

services. This information is essential for correct payment of the benefits due; failure to

show the amount paid is likely to result in excessive benefit payment to the provider

(including physicians and suppliers) (i.e., a benefit payment which, when added to the

amount already paid by the enrollee, will exceed the Medicare allowed amount).

EXAMPLE: The physician accepted assignment of a bill of $300 for covered services

and collected $60 from the enrollee, but failed to show on the claim form that he/she had

collected anything. The carrier determined the Medicare allowed amount to be $250, and

since the deductible had previously been met, made payment of $200 to the physician.

Since the physician would have received $190 in benefit payments and the enrollee $10 if

the amount collected had been shown on the claim form, the physician has been overpaid

$10. When this overpayment comes to light, e.g., by a complaint from the enrollee, the

carrier will take necessary corrective action, e.g., advise the physician to refund the $10

to the enrollee and if he/she fails to do so, pay the enrollee the $10 and recover the

overpayment from the physician.

C. Physician Should Not Bill Enrollee After the Claim is Submitted

After the provider (including physicians and suppliers) has accepted assignment he/she

should not bill the enrollee or try to collect from him/her any additional part of the bill

until he/she receives the carrier’s Medicare Summary Notice (MSN). Where the provider

(including physicians and suppliers) collects any substantial part of his/her bill from the

enrollee after submitting his/her claim, such collection is likely to be an overcollection,

and a violation of the assignment agreement. Furthermore, the enrollee who receives a

bill from the provider (including physicians and suppliers) may submit such bill to the

carrier with his/her own claim for benefits, causing confusion, possible duplicate

payment, or payment of benefits to the enrollee rather than the provider (including

physicians and suppliers).

EXAMPLE: The physician accepted assignment of a bill of $300 for covered services,

and collected $60 from the enrollee after the Form CMS-1500 had been filed with the

carrier, but before receiving notice of the Medicare allowed amount. The carrier

determined that the Medicare allowed amount was $250, and since the Form CMS-1500

did not show any payment made by the enrollee, paid the physician $200 (80 percent of

the $250 Medicare allowed amount). The result is that the physician has overcollected

from the enrollee by $10.

When this overcollection came to light through a complaint from the enrollee, the carrier

notified the physician that the $10 must be refunded to the enrollee. Unlike the excess

payment made because the physician fails to show the amount collected on the claims

form (see the example in B above), this $10 does not constitute a program overpayment;

the carrier should not apply recovery procedures applicable to overpayments, and should

not pay the $10 to the patient unless the physician first “refunds” it to the carrier (in lieu

of refunding it directly to the patient).

If the physician, after submitting his/her claim, collects an additional amount on his/her

bill, and the carrier learns of such collection before making SMI payment, the carrier

should adjust its payments to the physician and enrollee accordingly. However, even if

the physician collected the entire bill, requiring that the full SMI benefit be paid to the

enrollee, the Medicare allowed amount limitations of the assignment still apply.

D. Durable Medical Equipment Supplier Bills for Coinsurance at the Time Claim

Submitted

Notwithstanding the guideline in C above, a supplier of durable medical equipment may

bill the beneficiary for 20 percent of the Medicare allowed amount at the same time it

submits an assigned claim to the carrier for the items and services furnished, with the

exception of insulin that is administered through a covered item of DME. For such

insulin see Pub. 100-04 Chapter 20, – Durable Medical Equipment, Prosthetics,

Orthotics, and Supplies (DMEPOS), Section 140.1.1 for further instruction.

For all other items, the supplier must undertake:

1. To bill the beneficiary at the time it submits the claim only for 20 percent of the

Medicare allowed amount; and

2. To inform the beneficiary prominently on its invoice that:

a. It has submitted a claim to the carrier for the items and services and he/she

should not him/her self submit such a claim; and

b. The bill is for 20 percent of the Medicare allowable charge and is not covered

by Medicare; and

3. To establish and maintain adequate procedures for refund of any over collections

from the beneficiary that might result from the carrier approving a different

Medicare allowed amount than that submitted.