What are opportunities, pitfalls of billing non-assigned?

Andrea Stark, Jeff Baird weigh-in on new trend
Friday, August 12, 2016

YARMOUTH, Maine – When it comes to billing Medicare non-assigned—something more and more HME providers have been forced to do—there are misconceptions about what can and can’t be done, say industry consultants.

Andrea Stark says providers can, for example, charge beneficiaries “asking price” for products, because, unlike physicians, they’re not bound by a “limiting charge” when billing non-assigned. Medicare restricts physicians to collecting a max of 115% of the Medicare fee schedule.

“It completely removes that bind to the fee schedule allowable,” said Stark, a reimbursement consultant with MiraVista, who is writing a series of blogs busting myths about billing non-assigned.

But billing non-assigned is not a way to get around documentation requirements, Stark warns. Providers are still submitting claims to Medicare; they’re just collecting cash upfront from beneficiaries and asking the agency to pay beneficiaries, not them.

In fact, when billing non-assigned, the stakes may be even higher to meet documentation requirements, Stark says.

“If you don’t do it right and the claim denies for medical necessity reasons, you’ll have to pay back the patient,” she said.

Jeff Baird says providers don’t want to discriminate when billing non-assigned. Providers can’t, for example, bill non-assigned for product A for Medicare, but bill assigned for product A for a commercial insurer.

“That’s discrimination,” said Baird, chairman of the Health Care Group at Brown & Fortunato, who has been hosting webcasts on billing non-assigned for AAHomecare and state associations.

But in the example above, there is a “workaround,” Baird says.

“What you can do is say, we will take assignment from anybody so long as the reimbursement amount is $100 or more,” he said. “If Aetna pays $120, you bill assigned and get paid directly by Aetna. But if Medicare pays $80, the patient has to pay cash upfront and Medicare will reimburse them. That’s not discrimination.”

Another myth Stark busted on her blog: If an item isn’t coded, it doesn’t have to be billed at all.

“Just because a manufacturer doesn’t submit a walker for coding verification doesn’t mean you don’t know it’s a rolling walker and the code is E0143,” she said.

While there are intricacies to billing non-assigned, it’s worth the effort, Stark and Baird say.

“I look at it as an opportunity,” Baird said. “Up to this point, the DME industry has operated under an ‘assignment model.’ But effective July 1, providers are shifting to a ‘non-assignment model.’ We as an industry are standing on the edge of a cliff and we can’t back up anymore. We have to look at patients and say, ‘Sorry, but you have to feel some of the pain we’re feeling.’”