Billing for Services

Medicare

 

Covered Services

 

Laboratories can bill Medicare patients directly for covered services only in limited circumstances. For example, providers are allowed to bill beneficiaries directly when Medicare coverage for a covered service is denied for lack of medical necessity, but only if the provider issues a valid advance beneficiary notice of noncoverage (ABN) to the beneficiary.

 

The ABN is a government-approved form that allows beneficiaries to make an informed decision about whether to receive the item or service that may not be covered and accept financial responsibility if Medicare does not pay. The ABN describes the services to be provided, the reasons the provider believes that Medicare will not pay, and the estimated cost to the beneficiary. The beneficiary is directed to check a box to indicate whether or not he or she wishes to receive the service and be financially responsible if Medicare doesn’t pay. Lastly, the beneficiary is asked to sign the notice. Importantly, the ABN must be furnished before the patient receives the service to be valid.

 

See, e.g., Noridian ABN.

 

If the covered service would be paid by Medicare (e.g., because medical necessity criteria are met), a laboratory cannot bill a Medicare patient out of pocket for that service.

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Non-Covered Services

 

Laboratories can bill Medicare patients directly for services that are statutorily excluded from coverage under Medicare (i.e., care that is never covered) or care that fails to meet a technical benefit requirement. While an ABN is not required when billing patients for services that are never covered, it is recommended.

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Medi-Cal

 

Covered Services

 

Medi-Cal providers cannot bill Medi-Cal patients for covered services. “When Medi-Cal eligibility has been verified, providers must submit a claim for reimbursement according to the rules and regulations of the Medi-Cal program. Providers must not attempt to obtain payment from recipients for the cost of Medi-Cal covered health care services. Payment received by providers from DHCS in accordance with Medi-Cal fee structures constitutes payment in full.” Medi-Cal Provider Guidelines.

 

​Non-Covered Services

 

We did not identify any restrictions on billing Medi-Cal patients for noncovered services.

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Blue Shield of California

 

​Covered Services

 

IHD (as a contracted provider) cannot bill Blue Shield members for covered services. Blue Shield Independent Physician and Provider Manual Section 2.

 

Non-Covered Services

 

IHD (as a contracted provider) cannot bill a Blue Shield member for a non-covered service unless the member signs an “Acknowledgement of Financial Responsibility Form” prior to the date of service. To view and download a copy of this form, log in to Blue Shield’s provider portal at blueshieldca.com/provider, click on Find forms at the bottom of the page, then Patient care forms. The Acknowledgement of Financial Responsibility must include specific information regarding the non-covered service being provided, the date of service, the billed amount and a breakdown of the specific non-covered services being performed. See, Blue Shield Independent Physician and Provider Manual Section 2, Blue Shield Provider Standards (page 4).

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TRICARE

 

​Covered Services

 

A TRICARE participating non-network provider must accept the TRICARE-allowable charge as payment in full for a covered service. The provider cannot bill a TRICARE patient for a covered service.

 

A TRICARE non-participating non-network provider is not required to accept the TRICARE-allowable charge as payment in full for a covered service. This provider type can bill a TRICARE patient for a covered service.

 

See, TRICARE West, Network and Non-Network Providers.

 

​Non-Covered Services

 

We did not identify any restrictions on non-network providers billing TRICARE patients for non-covered services. Note that network providers must notify TRICARE patients in advance if services are not covered. The beneficiary must agree in advance and in writing to receive and accept financial responsibility for non-covered services. The agreement must document the specific services, dates, estimated costs, and other information. See, TRICARE, Hold Harmless Policy.