[ylbms]

Does anyone know....for a capped rental item (in this case it's a CPAP); the primary insurance is out of network/non-participating & only pays 50% of their allowed amount. The 13 month capped rental period has been met, so Medicare will not be paying any more. However, the purchase price has not been reached; can we still bill the patient for the 50% copay amount?
Thanks!

[leejgbt]

The answer partially depends on the assignment status. Here are the rules that apply:

Medicare secondary payments are based on the higher allowable charge between the primary insurer and Medicare unless the supplier is obligated to accept the primary insurer's allowable as payment in full. At no time will Medicare pay more secondary benefits than it would have paid as primary payer and all claims are subject to Medicare coverage criteria. The MSP payment calculation applies to assigned and non-assigned claims.

If the claim is filed assigned, the patient responsibility would be the difference between the Medicare allowed and the total amount paid.

"Obligated to Accept" is a term used when a supplier has a contractual agreement with the primary insurer to accept the primary insurer's allowed amount as payment in full. When the supplier is obligated to accept, the secondary payment is based solely on the primary insurer's allowed amount.

So, if you accepted assignment then you are probably done billing. If you went unassigned then you could balance bill the patient for the remaining amount up to the purchase price.