Is This Required Consent Legal?

C

coaster

Member
I need some procedures done as an outpatient at a local hospital where they require a patient's signature on a consent form that I believe contains language not in accord with U.S. healthcare law. This facility is listed by Medicare as accepting Medicare assignment, and my applicable primary insurance is Medicare Part B. The language in the document that I question is, and I quote :

'I agree that, should the amount covered by insurance or Medicare be insufficient to cover the entire facility expense, I will be responsible for payment of the difference'

It seems to me that by this consent I agree to waive applicable lawful limitations on what they are obligated to accepted as payment in full, and what I am obligated to pay as my portion of that payment in full ( as I understand them to be ).

Thoughts or advice on this? Any pointers to the applicable law and / or authoritative sources and documents I can supply to support me when I visit their business office?

Thanks so much for your responses!
 
The first question you need to ask is if they Accept Medicare or take Medicare Assignment. That can mean 2 different things

First if they Accept Medicare they agree to accept the Medicare Rates. Which means if the surgery is $5000 and Medicares rate for that surgery is $1000 they have to write of the additional $4000. In this situation Medicare would pay $800 and you would be responsible for $200

Second is if they take Medicare Assignment. This means that they are not contracted to accept medicare rates. However they can not charge you more then 15% above and beyond the Medicare rates (This is called Medicare part B Excess Charges) In this situation given the same numbers above you would be responsible for the initial 20% plus the extra 15% above the medicare allowable rates. They can not bill you for more then 15% if they accept Medicare assignment.
 
JCMedicare said:
The first question you need to ask is if they Accept Medicare or take Medicare Assignment. That can mean 2 different things

First if they Accept Medicare they agree to accept the Medicare Rates.
Click to expand...

Hi! Thanks for your response! Since posting the above, I got a book from Nolo Press, in which it says there's a loophole for 'Outpatient Admission', for which ( in the cases they accept Medicare as the primary insurer, but they don't accept 'Medicare Assignment', which dictates the amounts they're lawfully required to accept as payment in full ) I'm liable for whatever the difference is between what Medicare pays and what their billed fees are ( ie the 'Excess Charge' limits don't apply to outpatient fees ). Further comment?

BTW, if their billed fees were somewhere within the real world, in wouldn't be such a big deal. $2500 for a cardiologist to spend 10 or 15 minutes to 'read' an echocardiagram, for which all the 'real work' has already been done by the technician -- for another $2500. If this was a war, this would be 'war profiteering', for which at one time, the penalty was execution.
 
I am not sure what book you are referring to. Those that are not contracted to accept medicare could bill medicare under medicare Assignment. No one that accepts medicare accepts medicare assignment as they are already contracted to accept the medicare rates. No need for the medicare assignment

This is the form I pulled off of CMS.gov which is the center for medicare and medicaid services. You can see in this form it clearly states the following

Meaning of Assignment: For purposes of this agreement, accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program. Under an assignment, the approved charge, determined by the MAC/carrier, shall be the full charge for the service covered under Part B. The participant shall not collect from the beneficiary or other person or organization for covered services more agreement becomes effective __________________. than the applicable deductible and coinsurance.
 
Here is some more information I have found in this CMS Manual.

30.1.1 - Provider Charges to Beneficiaries
(Rev. 2921, Issued: 04-04-14, Effective: 05-05-14, Implementation: 05-05-14) In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program.

This includes items or services for which the beneficiary would have been entitled to have payment made had the provider filed a request for payment (see §50).

The provider may bill the beneficiary for the following items:
• Part A deductible;
• Part B deductible;
• First 3 pints of blood, which is called the blood deductible (if there is a charge for blood or the blood is not replaced);
• Part B coinsurance;
• Part A coinsurance; or
• Services that are not Medicare covered services.

See Chapter 30 for related requirements. SNFs may not require, request, or accept a deposit or other payment from a Medicare beneficiary as a condition for admission, continued care, or other provision of services, except as follows:
• A SNF may request and accept payment for a Part A deductible and coinsurance amount on or after the day to which it applies.
• A SNF may request and accept payment for a Part B deductible and coinsurance amount at the time of or after the provision of the service to which it applies.
• A SNF may not request or accept advance payment of Medicare deductible and coinsurance amounts.
• A SNF may require, request, or accept a deposit or other payment for services if it is clear that the services are not covered by Medicare and proper notice is provided.
See Chapter 30 for instructions about ABNs and demand bills.
• SNFs, but not hospitals, may bill the beneficiary for holding a bed during a leave of absence if the requirements in §30.1.1.1 are met.
 
I have found some other information for you in this CMS Manual

30.1.1 - Provider Charges to Beneficiaries (Rev. 2921, Issued: 04-04-14, Effective: 05-05-14, Implementation: 05-05-14)
In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program.

This includes items or services for which the beneficiary would have been entitled to have payment made had the provider filed a request for payment (see §50).

The provider may bill the beneficiary for the following items:
• Part A deductible;
• Part B deductible;
• First 3 pints of blood, which is called the blood deductible (if there is a charge for blood or the blood is not replaced);
• Part B coinsurance;
• Part A coinsurance; or
• Services that are not Medicare covered services.

See Chapter 30 for related requirements. SNFs may not require, request, or accept a deposit or other payment from a Medicare beneficiary as a condition for admission, continued care, or other provision of services, except as follows:
• A SNF may request and accept payment for a Part A deductible and coinsurance amount on or after the day to which it applies.
• A SNF may request and accept payment for a Part B deductible and coinsurance amount at the time of or after the provision of the service to which it applies.
• A SNF may not request or accept advance payment of Medicare deductible and coinsurance amounts.
• A SNF may require, request, or accept a deposit or other payment for services if it is clear that the services are not covered by Medicare and proper notice is provided. See Chapter 30 for instructions about ABNs and demand bills. • SNFs, but not hospitals, may bill the beneficiary for holding a bed during a leave of absence if the requirements in §30.1.1.1 are met.
 
I don't know anything about that book. My problem with books like that or articles people have written you can find online is that they are not always the most accurate information. I prefer going directly to the documents medicare and CMS put out to find the rules. You can research more at www.CMS.Gov
 
That's a valid point, except that, in my experience so far with government regs, pubs, docs and so forth, they cannot generally be understood by ordinary, uninformed folk like myself; that's why we need, and search for, informed and experienced help, such as yourself ;-)
 
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