Issues with Medicare Beneficiary Submitted Claims ‒ We Need Your Help

Table of Contents

• Issues with Medicare Beneficiary Submitted Claims ‒ We Need Your Help
• Summary of Beneficiary Submitted Claims
• Related Content
  • NGS Provider Outreach and Education
  • People with Medicare Education

[Return to Top]

Issues with Medicare Beneficiary Submitted Claims ‒ We Need Your Help

National Government Services has seen an increase of Medicare beneficiary submitted claims that often times result in a negative outcome. While most Medicare fee-for-service claims are submitted by a physician or practitioner, some Medicare beneficiaries find themselves in a situation where they must file their own Medicare claim. Please share the following with your members to help your patients understand when an order and referral occurs to another provider, check to make sure they are enrolled in the Medicare Program and understand the role they play in filing claims.

[Return to Top]

Summary of Beneficiary Submitted Claims

A physician or practitioner who wants to treat and receive payment for services provided to a Medicare beneficiary should stay in compliance with Medicare law by enrolling in Medicare and filing claims on the beneficiary’s behalf, or by opting out of Medicare and entering into a private contract with the beneficiary.

Providers can enroll in Medicare and choose to be either participating or nonparticipating. A provider that chooses to participate with Medicare agrees to always accept assignment for all Medicare-covered services. Providers that do not enter into a participation agreement with Medicare may choose on a claim-by-claim basis whether or not to accept assignment. If a nonparticipating physician does not accept assignment, then Medicare pays the beneficiary directly and the nonparticipating physician may bill the beneficiary up to the limiting charge amount.

A provider may also choose to opt out of Medicare (see Section 1802[b] of the Social Security Act [the Act]). Providers who properly opt out and maintain compliance with opt out requirement are excused from mandatory claim submission, assignment and limiting charge rules.

With the exception of those who have complied with opt-out procedures, when a physician or supplier furnishes a service that is covered by Medicare, and then attempts to charge and/or collect payment from the Medicare beneficiary, then the physician or supplier must submit a claim to Medicare. Physicians who violate the mandatory claim submission rules may receive a fine of up to $2,000 (see section 1848[g] [4] [B] of the Act).

[Return to Top]

Related Content

NGS Provider Outreach and Education

• Information for Physicians Who Refuse to Enroll, Opt-Out of the Medicare Program, or Submit Claims to Medicare
• Opt-Out and Private Contracting

[Return to Top]

People with Medicare Education

• Find a Physician and Other Clinicians
• Find a State Health Insurance Assistance Program for Local Help
• Call Medicare at 1-800-MEDICARE for Help at (1-800-633-4227); 24 hours a day/7 days week

Reviewed 7/27/2024