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  • CMS Relief Grant: Balance Billing Stipulation Due to COVID-19 Pandemic

    The details below apply to Provider Relief Fund Payment which — prior to April 21 — had the unique definition that all patients are considered potential COVID-19 cases. As of April 21, HHS changed their terms and conditions to state that the balanced billing requirement is only applicable for patients that are being treated for positive or presumed cases of COVID-19.


    • Balance billing is defined as an unanticipated or surprise out-of-pocket balance due from the patient related to services provided as out-of-network cost share.   One of the stipulations of the CMS Relief Grant is that physicians must agree to not collect out-of-pocket costs greater than the out-of-pocket expense from an in-network physician.
    • Balance billing is not defined as collecting an in-network copay/deductible or the Medicare 20 percent coinsurance/deductible. These balances are appropriate to collect.

    Bottom line: (Per the April 21 update, this applies only to treatment of COVID-19 itself, not to non-ophthalmic care of patients with COVID-19.)

    • Practices treat all insurances as if they are participating vs. non-participating or in-network vs. out-of network.
    • Every physician is participating or considered in-network.
    • Physicians should not collect a deposit from the patient.
    • Important:  Don’t bill more than the in-patient network balance.

    Physicians can't rely on amounts listed in remittance advice to be accurate, so how can they find out what participating/in-network allowables look like?

    • Check to see if allowables are listed on the patient's insurance card.
    • Visit the payer's website.
    • Call the provider relations representative.

    Write-off will not be your typical write-off code
    The write-off should reflect Public Health Emergency.

    Collecting out-of-network benefits
    To maintain the ability to collect on out-of-network benefits, you would need to return the stimulus funds to HHS.


    Medicare Primary, Medigap Secondary
    A claim is submitted to Medicare Part B for $150. $100 is allowed. Medicare pays 80 percent or $80 and the coinsurance balance is $20.00. The physician writes off $50 as a participating physician. The balance of $20 is then submitted to secondary insurance (Medigap) and they pay $15.00. The balance of $5.00 should be collected from the patient whether the practice is participating or non-participating.

    Commercial Plan – Out-of-Network
    During the Public Health Emergency (PHE) a patient is seen in the office for urgent care. The ophthalmologist is an out-of-network or non-participating physician for the commercial plan. The claim is submitted to the commercial payer for $300 and is processed as out-of-network. The insurance pays the physician $120 or 60% of the allowable of $200. The remittance advice (RA) indicates the patient responsibility is $180.00. An in-network physician would be paid 80% of the allowable, with a contractual adjustment and a patient responsibility of $40. The out-of-network balance should be adjusted to $40 during this PHE.

    Medicare Advantage, In-Network
    An established patient is seen for urgent care. The physician participates with the patient’s Medicare Advantage plan. The copay for in-network providers is $20 which should be collected from the patient.

    Commercial plan, In-Network
    An established patient is seen. Allowables for the exam and test is applied towards the patient’s large deductible. The patient should be billed their deductible.

    View updates on telemedicine coding to use in your practice based on guidelines from CMS.