Medicare Misinformation

The Office of Healthcare Systems and Financing (OHSF) has received several calls in the past months from members who have received incorrect billing advice from their local Medicare carriers.

Ellen Jaffe, who handles Medicare questions for OHSF, warns members: “It’s like anything else. If what you hear sounds too good to be true, or in the case of the Medicare program, too easy to be true, it probably is.”

Jaffe reports that an APA member was told by a representative of the Pennsylvania carrier, HGSA, that nonparticipating providers in Medicare were permitted to charge their customary fees. In fact, nonparticipating providers may charge only up to the “limiting charge,” which is 115 percent of the Medicare-allowed amount for any service.

A member in Southern California was told that instead of opting out, he could charge Medicare patients his customary fees if he “voluntarily deactivated” his Medicare enrollment. In fact, if this were done and the psychiatrist saw a Medicare patient, he would have to re-enroll in Medicare because he would have a legal obligation to submit a claim to Medicare for the service he provided—and he could charge only the Medicare-allowed amount.

Filing an opt-out affidavit with your Medicare carrier and establishing private contracts with Medicare beneficiaries is the only way you can legally charge Medicare beneficiaries your customary fees rather than the Medicare-allowed fees for the Medicare-covered services you provide them.

If you believe you have been given misinformation by your Medicare carrier, contact Ellen Jaffe through the Managed Care Help Line by phone at (800) 343-4671 or by e-mail at [email protected]. She will get in touch with the carriers and make every effort to ensure that incorrect information is no longer disseminated. General information about opting out of Medicare can be found in the Members Corner of APA’s Web site, www.psych.org.