National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Charges for Missed Appointments (MM5613)

Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare contractors (carriers, fiscal intermediaries (FI), or Part A/B Medicare administrative contractors (A/B MAC))

Provider Action Needed

Impact to You
The Centers for Medicaid & Medicare Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. However, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare.

What You Need to Know
Providers may not charge ONLY Medicare beneficiaries for missed appointments; they must also charge non-Medicare patients. The amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients.

What You Need to Do
Make certain that your billing staff is aware that you may bill the beneficiary directly, that Medicare itself does not make any payments for missed appointments, and that Medicare should not be billed for these charges.

Background
According to Chapter 12, Section 30.3.13 of the Medicare Claims Processing Manual, which is attached to CR5613, CMS policy allows physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments and the charges for Medicare and non-Medicare patient are the same. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician’s or supplier’s missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.

The other key points of CR5613 are:

• The provider may bill the Medicare beneficiary directly.
• Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers.
• Claims for missed appointments sent to Medicare will be denied with the reason code 204 (This service/equipment/drug is not covered under the patient’s current benefit plan.).
• In most instances, a hospital outpatient department can charge a beneficiary a missed appointment charge.
• In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5613) issued to your Medicare carrier, FI or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1279CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, FI or A/B MAC, at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5613
Pub. 100-4, Transmittal# R1279CP, CR# 5613
Related CR Release Date: June 29, 2007
Effective Date: October 1, 2007
Implementation Date: October 1, 2007