Quote:
Originally Posted by cdnus
I know this sounds simplistic---But why can't the Hospitals/doc's just charge their patients a Top Up fee rather than drop them stone cold to fend for themselves????
Or does medicare not allow for this practise.
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Because that would then be fraud. Every medical service has a code associated with it, and each code is reimbursed by medicare for a set fee as determined by them. To "up-Charge" would be to bill for a higher reimbursement code that was not actually provided, and therefore be considered fraud. If you are audited by medicare, they go through your charts and billing to see if you have the proper documentation supporting your charges. If there are discrepenceies, favoring the doctor, they are considered fraud, and I think are subject to a $5000 fine for EACH OCCURANCE.
When a hospital or doctor signs up with Medicare, Medicaid, BWC, or any insurance company, what they are doing is agreeing to accept a set reimbursement fee set by the insurance provider such that the medical provider cannot bill the patient in excess of this. The only way to get around this is to "opt out", that is, terminate the agreement making the patient fully responsible, with the exception if the insurance provider provides "out-of-network" benefits, then the insurance will pay part of the bill. Medicare, Medicaid, BWC have no out of network benefits, as with some other insurance plans, and therefore the patient owes the full balance unless the medical provider grants a discount for cash pay.