Billing patient for ASC charges

Charging the Patient

ASC facilities may charge the patient for deductible and coinsurance of covered procedures performed in the ASC facility. If a procedure/service is performed outside of the CMS published procedure listing, the billed charge would be denied by Medicare. The denial message to the ASC facility indicates, “Payment is adjusted because treatment was deemed by the payer to have been rendered in an inappropriate place of service.” There will also be a Medicare remittance advice to the beneficiary that indicates, “The service cannot be paid when provided in this location or facility.” Along with the message to the ASC facility, there is another statement that indicates the provider is under contractual obligation and the patient is responsible for this type of denied charge.

CMS has determined that the only surgical procedures excluded from ASC payment are those that pose a significant safety risk to beneficiaries or are expected to require an overnight stay when furnished in an ASC. Therefore, CMS provides no payment to ASCs for these procedures.

Note: CMS does not expect that these unsafe services will be furnished to Medicare beneficiaries in ASCs, and CMS expects that physicians and ASCs will advise beneficiaries of all of the possible consequences (including no Medicare ASC payments with concomitant beneficiary liability and significant surgical risk) if surgical procedures excluded from ASC payment were to be provided in ASCs.

MLN Matters MM 6052/Change Request (CR) 6052 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6052.pdf

Medicare encourages ASC facilities to discuss what services are payable when performed in an ASC facility with all physicians that perform procedures at their facility. This will assist the facility with services being non-covered due to the ASC procedure limitations.