An assignment is an agreement between a provider and the Medicare patient. Under the terms of the assignment, the Medicare patient transfers to the provider his/her right to benefits for covered services specified on the assigned claim; the provider in return agrees to accept the Medicare approved charge as his/her full charge for the items or services.
A provider who accepts assignment is prohibited from charging its Medicare patients more than the deductible and coinsurance of the approved allowance. A participating provider must accept assignment for all covered services. A nonparticipating provider may accept assignment on a claim by claim basis. Item 27 of the CMS-1500 claim form (or equivalent record field for electronic transmissions) must be checked “Yes” by participating providers. Nonparticipating providers may check either “Yes” or “No.” If “Yes” is checked, the nonparticipating provider has agreed to accept Medicare’s approved allowance as his/her full charge for that claim.
In certain situations, a provider, regardless of his/her participating status, must submit an assigned claim to Medicare. The following are instances when an assigned claim is mandatory.
Submit the claim to Medicare. Medicare will automatically forward payment information directly to Medicaid if the claim has been properly completed.
Services provided by the following nonphysician practitioners:
The mandated assignment requirement also applies to routine venipuncture for collection of specimen(s). A specimen collection fee is allowed in circumstances such as drawing a blood sample through venipuncture or collecting a urine sample by catheterization. A specimen collection fee is not allowed where the cost of collecting the specimen is minimal, such as throat culture or a routine capillary puncture for clotting or bleeding time, or routine sticks of the finger, heel, or ear.
The provider may not collect from the Medicare patient on clinical lab unless it is determined by Medicare to be not medically necessary and a written ABN form was obtained prior to the services being performed.
Payment for clinical laboratory services is reimbursed at 100 percent of the fee schedule amount. Neither the deductible nor the coinsurance applies and may not be collected from the Medicare patient.
Providers should submit a claim only if the clinical laboratory service is actually performed and interpreted in his/her office. If the specimens are sent to a laboratory, the laboratory must file the claim.
Sanctions of double the violative charges, civil monetary penalties (up to $2,000 per violation) and/or suspension from the program for up to five years may be imposed upon providers and laboratories, except rural health clinical laboratories, who knowingly, willfully and repeatedly bill patients on an unassigned basis for clinical laboratory tests.
Participating physicians and nonparticipating physicians who selectively submit assigned claims may collect payment from their Medicare patients only for:
It is suggested that the provider notify the Medicare patient that the service is not covered.
At no time may a provider who accepted assignment:
If it is determined that you have collected in excess of the Medicare patient’s total liability, the provider must refund any overpayment to the patient. However, even if they promptly refund the patient, it is an assignment violation to collect more than applicable amounts. If the provider knowingly, willfully, and repeatedly violates the assignment agreement, they are guilty of a misdemeanor and subject to a fine of not more than $2,000 or imprisonment of not more than six months or both.
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30