TN 1 (10-22)

HI 00401.325 Effect of Waiver of Coinsurance or Deductible on Determination of Actual and Customary Charges

The criteria that the carrier considers in determining the reasonable charge (HI 00401.305) for a service or item include (in addition to the prevailing charge HI 00401.320) the customary charge (HI 00401.315) of the physician or supplier who furnished it, and the actual charge made. In this regard, a billed amount that is not reasonably related to an expectation of payment is not considered by the carrier to constitute the “actual” charge.

Therefore, when a physician/supplier routinely and consistently waives the collection of coinsurance or deductible amount, from or on behalf of Medicare beneficiaries generally, the carrier reviews the circumstances to determine whether this constitutes a reduction of the physician's or supplier's actual charges and customary charges.

Situations where a physician or supplier does not have a general policy of waiver of coinsurance but accepts a lesser amount than the usual charge in discharge of a patient's liability because of a particular patient's straitened circumstances will not be considered to constitute a reduction of the actual charge made.

If the DO learns of a physician's or supplier's prior advertisement of a general intention to waive collection of Medicare coinsurance or deductible amounts, or other evidence that such waiver is settled business policy; or that the physician/supplier generally fails to make reasonable collection efforts (similar to those customarily made to collect comparable amounts from non-Medicare patients), report this information to the carrier.