CMS Pub. 100-04, ch. 23, § 80.8.1

B3-5220

Physicians or suppliers who routinely waive the collection of deductible or coinsurance

from a beneficiary constitute a violation of the law pertaining to false claims and

kickbacks. These situations should be referred to Program Integrity area for additional

investigation according to the procedures in the Medicare Program Integrity Manual.

Deductible and coinsurance amounts are taken into account (included) in determining the

reasonable charge for a service or item. In this regard, a billed amount that is not

reasonably related to an expectation of payment is not considered the “actual” charge for

the purpose of processing a claim or for the purpose of determining customary charges.

Where a physician/supplier makes a reasonable collection effort for the payment of

coinsurance/deductibles, failure to collect payment is not considered a reduction in the

physician’s/supplier’s charge. To be considered a reasonable collection effort, the effort to

collect Medicare coinsurance/deductible amounts must be similar to the effort made to

collect comparable amounts from non-Medicare patients. It must also involve the issuance

of a bill to the beneficiary or to the party responsible for the patient’s personal financial

obligations. In addition, it may include other actions, such as subsequent billings,

collection letters and telephone calls or personal contacts which constitute a genuine, rather

than token, collection effort.