Don't charge Medicare “substantially” more than your private payers; 21% is one guideline

Why This Topic Matters

Understanding how Medicare charge levels relate to other payer rates can help practices evaluate compliance risk when setting fee schedules and negotiating payer contracts. The article is relevant to offices that use multiple pricing structures or have Medicare as a secondary payer.

Article Sections

1. Medicare charge standard and enforcement perspective

   Introduces the legal framework governing Medicare charges compared with other payers and summarizes the enforcement context discussed by the article.

2. Interpreting the standard and advisory guidance

   Reviews the ambiguity in the standard and references advisory guidance and professional opinions about how practices assess risk under the law.

3. Multiple fee schedules and payer contract considerations

   Discusses differing views on whether more than one fee schedule is advisable and the general concerns raised by discounted contract arrangements.

4. Secondary Medicare and non-insurance patient pricing

   Covers additional practice scenarios involving Medicare as a secondary payer and pricing approaches for patients without insurance.