Medicare Billing and Payments

(2/6/15)- A spokeswoman for the Centers for Medicare and Medicaid Services (CMS) said the government will begin releasing Medicare Part B medical payments records every year, after last year, when that data was first released for public consumption.

That information was released as a direct result of a suit brought by Dow Jones & Co., the parent of the Wall Street Journal challenging a 1979 injunction that prohibited Medicare from disclosing its payments to physicians. A year’s worth of data was released in April, but it was unclear at that time if any more information would be made public.

The data that was published detailed payments of more than $77 billion to about 880,000 individuals and organizations covering the year 2012. A federal judge vacated the injunction in 2013.

CMS did not say when it expected to publish the information. The data released in April included payments to doctors, laboratories, ambulance companies and other medical providers under Part B, which makes up about one-seventh of the program’s nearly $600 billion in annual expenditures.

(7/31/13)- The Centers for Medicare and Medicaid Services (CMS) said that 9,539 physicians who had accepted Medicare opted out of the program in 2012, up from 3,709 in 2009. That compares with 685,000 doctors who were enrolled as participating physicians last year.

Once a doctor opts out of Medicare/Medicaid, he/she can't apply to re-enter it until at least a 2 year wait.

According to a survey from the American Academy of Family Physicians, which has 800 members, 4% are now in cash-only or concierge practices, where patients pay a monthly or yearly fee for special access to doctors, up from 3% in 2010.

A study in the journal Health Affairs found that 33% of primary-care physicians did not accept new Medicaid patients in 2010-2011.

(8/29/07)- Effective October 2008 Medicare will stop paying hospitals for treating eight "reasonably preventable" conditions acquired within the hospitals. This rule change was mandated under legislation passed in 2005. Medicare officials announced also that there would be an additional 3 conditions that they would added to this list in 2008.

The eight conditions include injuries from patient falls in the hospital, pressure ulcer sores, urinary-tract infections, vascular-catheter-associated infections and mediastinitis, an infection following heart surgery. Also included are so-called never events, meaning they never should happen: objects left in the body during surgery, air embolisms and blood incompatibility.

These changes are part of the attempt by Medicare to cut down on their expense, which totaled $406 billion in 2006. Since October 2006, hospitals have been required to report certain quality data or face a penalty. Beginning in October 2008, Medicare will increase the number of quality measurements to 27.

(4/16/07)- The following is an email that we received from one of our viewers, and Harold Rubin's response to that email:

----- Original Message -----

Sent: Wednesday, April 11, 2007 10:57 AM
Subject: Question

Hello There!
My name is Irene (deleted) and I live in Seattle. My sister lives in Kent, Connecticut, and recently placed my 85 year-old mother in (deleted). She is on Title 19.
My sister claims that Title 19 benefits do not cover dental, eye exams, glasses or dentures. I think she is mistaken.
Can you please give me some info on this?
A list of providers in the area would be greatly appreciated as well.
I took the day off from work to research this, so I will have access to my email all day.
Thank you so much!
Irene (deleted)

Dear Ms.

Below you will find what Title 19 covers. Each state has to match 40% of the funds given by federal government. Each state has an agency which monitors section 19. We are not experts on section 19, but believe it covers medical services for eligible individuals but not dental services, unless it involves medical emergency. You will have to check with the State of Conn. for this type of information. You may find the information on the following site helpful- This is the site of a lawyer who specializes in elderly law. We are not aware of anything about this firm. We found it by searching the web. The information provided appears to be legitimate. The State of Conn Aging Services Division can be found at They should be able to give you the answers to your questions

We hope this answers some of your questions. Feel free to contact us for further information

Title XIX of the Social Security Act is administered by the Centers for Medicare and Medicaid Services.
Title XIX appears in the United States Code as §§1396-1396v, subchapter XIX, chapter 7, Title 42.
Regulations relating to Title XIX are contained in chapter IV, Title 42, and subtitle A, Title 45, Code of Federal Regulations.
See Vol. II, 31 U.S.C. 6504-6505 with respect to intergovernmental cooperation. See Vol. II, 31 U.S.C. 7501-7507 with respect to uniform audit requirements for State and local governments receiving Federal financial assistance.
See Vol. II, P.L. 78-410, §317A(a) and (d), with respect to coordination required in lead poisoning prevention; §353(i)(3) and (n), with respect to clinical laboratories; and §1301(c)(3), with respect to the requirement that health maintenance organizations enroll individuals entitled to medical assistance under Title XIX.
See Vol. II, P.L. 79-396, §17(p), with respect to proprietary title XIX center.
See Vol. II, P.L. 88-352, §601, for prohibition against discrimination in federally assisted programs.
See Vol. II, P.L. 89-73, §§203 and §306(c) with respect to agreements with other agencies.
See Vol. II, P.L. 94-566, §503, with respect to preservation of medicaid eligibility for individuals who cease to be eligible for supplemental security income benefits on account of cost-of-living increases in social security benefits.
See Vol. II, P.L. 95-521, §102(i), with respect to reporting of benefits received under the Social Security Act
See Vol. II, P.L. 99-319, §105, with respect to requirements for a system established regarding the rights of individuals with mental illness.
See Vol. II, P.L. 100-203, §4211(j) with respect to technical assistance with respect to the development and implementation of reimbursement methods for nursing facilities.
See Vol. II, P.L. 100-204, §724(d), with respect to furnishing information to the United States Commission on Improving the Effectiveness of the United Nations; and §725(b), with respect to the detailing of Government personnel.
See Vol. II, P.L. 100-235, §§5-8, with respect to responsibilities of each Federal agency for computer systems security and privacy.
See Vol. II, P.L. 100-690, §2306(c)(4), with respect to services covered in the plan of Hawaii; and §5301(a)(1)(C) and (d)(1)(B), with respect to benefits of drug traffickers and possessors.
See Vol. II, P.L. 101-121, with respect to the amounts collected by the Secretary of Health and Human Services under the authority of title IV of the Indian Health Care Improvement Act.
See Vol. II, P.L. 101-239, §6507, with respect to research on infant mortality and medicaid services; §6509, with respect to a maternal and child health handbook.
See Vol. II, P.L. 101-508, §4401(d), with respect to an annual report on drug pricing; §13302, with respect to protection of OASDI Trust Funds in the House of Representatives.

(9/3/05)- Medical care is one of the few industries where the consumer has very little idea as to what the cost of the service actually is for which he is being charged. In my own case my medical bill goes to my insurer to pay, and I did not even know what I was being charged.

One day I decided to go onto my own personal medical site at my insurer's Web site to see what I was being charged and what my insurer was actually paying for the service. It came as a great shock to me when I saw what I was being charged, and what the insurer was actually paying the medical professional for the service or the lab bill. Sure I was paying a co-pay or even the deductible, but I was being a lousy consumer in not looking to see what I was being charged.

Keep in mind that the premiums I was paying was increasing by a large percentage every year, and because of my own failure to watch what the costs actually were, I was guilty of helping to increase medical costs without even knowing what those costs truly were.

In the same vein Aetna Inc., the large health insurance company has put online the prices that it pays to Cincinnati-area doctors for hundreds of medical procedures and tests so that its members can do some comparative shopping when it comes to medical and lab test charges. The company hopes to expand the listing to other areas of the country with the passage of time

Aetna is the first major health insurance company to publicly disclose the fees it negotiates with physicians. The price list includes over 600 common services for which it receives medical claims.

(1/30/03)-It would seem to us that many individuals are confused about the Medicare bill they receive and how much they need to pay their treating physician. In prior articles, we have tried to make this clear, but feel it needs repeating. The physician can choose from a number of options. The costs of the service performed by the physician are dictated by a complicated formula worked out by the federal government. (The following information was taken from an AMA published guide for physicians.)

Billing Options That Physicians Can Opt For:

  1. PAR: in this option, the physician has signed a participation agreement to accept Medicare’s allowed charge as payment in full.
  2. Non-PAR: in this option the physician elects to be a non-participant, thus permitting billing patients for somewhat more than the Medicare allowance
  3. Private Contractor: in this option the physician bills the patient directly and forgoes any payment from Medicare either to patient or the physician.

Participating Physicians (PAR)

In this program, the agreement stipulates that the participating physician must accept Medicare’s approved amount as payment in full for all covered services. The patient is responsible for Medicare deductible and 20% co-insurance. However, the doctor cannot charge more than the Medicare allowances for the type of visit.

The incentives for the Physician to participate in this billing option include:

  1. The amount Medicare pays the physician is 5% higher than for Non-PAR physicians (see below).
  2. Directories of PAR physicians are provided to senior citizens so that they can choose a physician, a form of medical advertising to get patients
  3. Carriers provide toll-free claims processing lines to PAR physicians and process their claims more quickly, resulting in a faster cash flow for the physician.

Non-Participating Physicians (Non-PAR):

With non-participating physician, the full payment schedule is set at 95% of the full payment schedule for PAR physicians. For the same service, Non-PAR can only get 95% of the PAR amounts.

Here is where the billing gets complicated and confusing to many physicians and patients. Limiting charges for Non-PAR physicians are set at 115% of the Medicare approved amount for Non-physicians. (In New York State, the full-limiting charge is set at 105% of the Non-Par fee schedule.)

Since Medicare payment schedule amounts for Non-PAR physicians are 95% of payment rates for PAR physicians, the 15% limiting charge translates into only 9.25% above the PAR approved amount for the service. (In NY State, this percentage is even less.)

Monies must be collected from patients in this program as opposed to the PAR program where the money comes directly from the Government. Thus non-PAR physicians must deal with bad debts, collection costs etc. According to a guide published by the AMA, doctors need to collect the full-limiting charge amount about 35% of the time for the revenue from the service to equal those of the PAR physicians. It is why doctors want to collect fees at the time of service, introducing credit card payment etc.

Private Contractors (Opt out physicians)

When the Balanced Budget Act of 1997 was passed, a rider to the bill gave physicians and Medicare patients the choice of privately contracting to provide health care services outside of the Medicare system. However, private contractors had to meet certain requirements:


Surveys indicate that doctors are limiting the number of their new Medicare patients, following the cut of 5.4% the year before. At the same time, rates paid by private insurance companies are also being lowered.

Chris Hogan, PhD., a consultant with Direct Research on behalf of the Medicare Payment Advisory Commission stated: "The gap between Medicare and private rates closed over the decade, but it closed because [private] rates fell while Medicare rates more or less kept pace with the rate of inflation."

Another study, by Zachary Dyckman, PhD, found that Medicare rates in 2002 were between 83% and 87% of private rates. He implied that if Medicare rates keep dropping there would be more pressure to raise physician fees in private health plans, resulting in higher premiums for the consumer. This form of cost shifting can only hurt the consumer.



Allan Rubin and Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated February 6, 2015

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