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089385 1 (1975-10-08)

handle is hein.gao/gaobacviy0001 and id is 1 raw text is: UNITED STATES GENERAL ACCOUNTING OFFICE o i1 REGIONAL OFFICE 26 FEDERAL PLAZA NEW YoRK, NEw YoRK 10007 Mr. Elmer W. Smith, Regional Commissioner Social and Rehabilitation Service, Region II Department of Health, Education and Welfare 26 Federal Plaza New York, New York 10007 Dear Mr. Smith: On August 1, 1975, we met with Messrs. William Toby and Stanley Allen of your staff to discuss Medicaid overbillings by the New York City Health and Hospitals Corporation (1HHG) for outpatient department ;e clinic services applicable to individuals covered under both the Medicare and Medicaid programs (dual beneficiaries). This letter confirms the information we supplied at that meeting. Outpatient hospital services are covered under.part B of Medicare, and assuming the beneficiary has met the annual $60 part B deductible, are subject to a 20 percent coinsurance provision which is the responsibility of the beneficiary. The program reim- burses the institution on the basis of 80 percent of reasonable costs, which are subject to retroactive audit and adjustment, and the coinsurance portion is usually calculated and collected on the basis of 20 percent of the reasonable charges. For a dual benefi- ciary however, the coinsurance and deductible amounts are paid by Medicaid. The Code of Federal Regulations (CFR), Title 45, Parts 249.41(b) and (c)(2), 250.30(b)(3)(ii), and 250.31(b) taken together require, in effect, that (1) all providers should bill Medicare first, then, (2) bill Medicaid for the coinsurance and deductibles not covered by Medicare, and (3) the combined payments from Medicare and Medicaid should not exceed what would have been paid by the program and the beneficiary under Medicare. Both the Bureau of Health Insurance (BHI) Program Officer, Peimbursement Branch, Region II, and a SRS Medical Services Specialist have confirmed these requirements. BEST DOCUMNT AVAILABLE

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