• How to Bill for Patients Seen While Incarcerated


    Patients in the penal system have eye care needs, just like the rest of the population. But when an ophthalmologist treats such patients, it’s not always clear whom to bill.

    What constitutes a patient ‘in custody’

    Patients considered in custody may include all of the following:

    • Under arrest;
    • Incarcerated;
    • Imprisoned;
    • Escaped from confinement;
    • Under supervised release;
    • On medical furlough;
    • Required to reside in mental health facilities;
    • Required to reside in halfway houses;
    • Required to live under home detention;
    • Confined completely or partially in any way under a penal statute or rule.

    Who pays for in-custody patients

    Mostly likely, the federal, state or local authority that has the patient in custody will be responsible for the charges.

    The Centers for Medicare and Medicaid Services states that it is no longer responsible for payment when a patient has no legal obligation to pay for benefits, or when a governmental entity pays for the services.

    While you will usually bill the authority that has the patient in custody, some exceptions exist, under which CMS may be responsible.

    1. If the state or local law indicates the patient must repay them for medical services received during incarceration; and
    2. The authority in question enforces this by collecting any debt owed:

    The authority will alert the practice that the patient meets the exception rule under the Code of Federal Regulations statute. At this time billing Medicare may resume.

    How to get paid for treatment

    Once you’ve established that the patient meets one of the conditions listed above, verify his/her status through your Medicare administrative contractor interactive voice response unit. The contractor should show an inactive status.

    • Non-Medicare patients: Inactive status may occur for a variety of reasons, so be sure to get additional details from the patient in order to submit the claim to the correct party.
    • Medicare patients, under the exception rule: Submit with modifier -QJ Services/items provided to a prisoner or patient in state or local custody, provided the state or local government, as applicable, meets the requirements in 42 CFR 411.4(B).

    Carefully track any billing to ensure you receive proper payment and follow the guidelines put forth by Medicare.

    Related: Best of E-Talk: Giving Out Prisoner Medical Information