Last week, I wrote about the ins and outs of Medicare participation (you can read that here). This week, I thought I would shine a little light on claim assignment.

Next Episode: Thursday, June 20, 2024

What is Medicare assignment? When a participating supplier accepts assignment – as they must – the beneficiary transfers to the supplier his or her rights to receive Medicare reimbursement for covered services. In exchange, the supplier agrees to cap their charges to the applicable Medicare allowable amount. Medicare pays its portion directly to the supplier, and the patient is only responsible for the co-insurance or deductible. While Medicare requires participating suppliers to accept assignment on all covered claims, non-participating suppliers can accept assignment on some claims and not on others. When a non-participating supplier accepts assignment, the claim is treated exactly as I described for participating suppliers. When a non-participating supplier does not accept assignment:
  1. The patient pays the supplier’s full usual and customary charge amount to the supplier directly.
  2. The supplier files a Medicare claim on the patient’s behalf.
  3. Medicare reimburses the patient the Medicare allowed amount.
Assignment is, with a few caveats, a claim-level choice. As a practical matter, Medicare applies the assignment decision to all claim lines for an individual beneficiary that share the same service date. How do non-participating suppliers elect assignment on a claim? Accepting assignment, or not, is as simple as checking a box on the 1500 claim form (or the electronic equivalent): Box 27 of the CMS 1500 Claim Form If a participating supplier checks “no,” the DME MAC will override the choice to “yes” because Medicare requires participating suppliers to always accept assignment. Should suppliers accept assignment? Assignment comes with certain conveniences, namely Medicare pays the supplier directly. Furthermore, suppliers are not required to obtain monthly beneficiary authorizations for capped rental items when they accept assignment on the first rental claim. Those conveniences, however, may not be worth it if the Medicare rate is too low to offer certain products and maintain a profit margin. In those cases, opting out of assignment may be the right decision. As a practical matter, we recommend non-participating suppliers choose a default assignment decision that will cover the bulk of Medicare activity. Default operational policies with documented exceptions are easier to follow and easier to enforce. So that’s Medicare claim assignment in a nutshell. Give us a shout if you have questions or if we can assist you in any way as you build and maintain your team’s reimbursement mastery. Take care, Andrea