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