Billing non-assigned: Myths, part 2

Andrea Stark
reimbursement consultant, MiraVista

Editor's note: In the wake of new market pressures, upgrades, non-assigned claims and cash sales are taking center stage, says industry consultant Andrea Stark. The market has changed and your business should contemplate the suitability of these options, but they are not appropriate in all cases, she says. This is the second in a series of mini-articles that break down the top myths of filing non-assigned claims and leveraging upgrades and cash sales.

Myth #2:  DME suppliers are bound by a “limiting charge” when billing non-assigned, and beneficiaries cannot be charged more than a certain percentage over the Medicare fee schedule allowable.

This is FALSE.

The “limiting charge” concept applies to Part B services like physician visits, but does not apply to durable medical equipment. The limiting charge restricts physician collections to a maximum of 115% of the Medicare fee schedule when they file non-assigned. Physicians are further subject to a participation penalty when they do accept assignment (non-participating physicians receive a maximum of 95% of fee schedule amounts when they do accept assignment). Neither the participation penalty nor the limiting charge apply to durable medical equipment. The CMS publication titled “Medicare Coverage of Durable Medical Equipment and Other Devices” states, “If a DME supplier doesn’t accept assignment, there’s no limit to what they can charge you.”