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Every surgical office should have an Elective Surgery Form on hand for any Medicare Beneficary. Even if you have informed the patient the surgery is elective and not covered by Medicare Part B, you must have a signed form to bill the patient. See the sample below:

Notices for Elective Surgery

Elective surgery for Medicare purposes is defined as surgery that can be scheduled in advance, is not an emergency, and, if delayed, would not result in death or permanent impairment of health.

To be considered an emergency, the condition for which surgery is needed must meet the definition of “emergency medical condition” as specified in section 1903(v)(3) of the Social Security Act. Section 1903(v)(3) of the Act defines “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

• placing the patient's health in serious jeopardy
• serious impairment to bodily functions
• serious dysfunction of any bodily organ or part

If you do not notify the beneficiary prior to furnishing the services, you must refund any money collected from the beneficiary in excess of the Medicare payment. If you fail to refund the money, you may be subject to civil money penalties and/or exclusion from the Medicare program.

Document the beneficiary's receipt and acknowledgment of the required information contained in the notice by having the beneficiary or his/her representative sign and date the notice. Keep a copy of the notice in your files. You are required to produce copies of these notices upon request.

If you are performing surgical procedures with estimated actual charges of at least $500 for which we have not provided the Medicare allowed amount, please contact us and identify the procedure for which you need charge information. (This requirement also applies to anesthesia services personally administered by the primary or assistant surgeon.)

Note: The actual billed or collected charge may not be greater than the limiting charge amount, i.e., 115 percent of the Medicare approved amount for nonparticipating physicians. The sample letter to the beneficiary and the worksheet shown on the following page should display an amount within the limiting charge. The beneficiary is not financially liable for a higher amount even though he or she agrees to the elective surgery on a non-assigned basis. Beneficiaries are entitled to a refund of money billed or collected above the limiting charge.

The following is a worksheet to determine your patient's estimated Medicare payment for elective surgery:

• Your actual charge
• The Medicare allowed amount
• The Medicare approved charge (the lower amount of number 1 or 2 from above)
• The difference between your actual charge and the Medicare approved charge (number 1 minus number 3)
• Twenty percent coinsurance (.20 multiplied by the total amount in number 3)
• Beneficiary's out of pocket expenses (number 4 plus number 5)

Assume the $100 deductible has already been met. Include the amount in numbers 1, 3 and 6 in your letter to the beneficiary.

Sample Beneficiary Letter

Date:

Dear (Beneficiary's Name):

I do not plan to accept assignment for your surgery. The law requires that where assignment is not taken, and the charge is $500 or more, the following information must be provided prior to surgery. These estimates assume that you have met the $100 annual Part B Medicare deductible.

Type of surgery __________________
Estimated charge __________________
Medicare estimated payment ____________
Your estimated payment (includes your Medicare coinsurance) __________

Sincerely,
(Physician's Signature)