How do providers and suppliers obtain payment for the services covered by the Medicare Set-aside and at what rate may they charge?
A51. There are two distinct methods for providers, physicians and other suppliers to obtain payment for workers’ compensation covered medical services and prescription drug therapy charges when funds are held in a Medicare Set-aside. Determining which distinct payment method applies depends on whether the Medicare Set-aside was priced by contemplating full actual charges or a workers’ compensation State fee schedule. In no case is the payment based on Medicare approved rates. If the Medicare Set-aside is based upon a State fee schedule physicians and other suppliers will be paid based on what would normally be payable under the State’s workers’ compensation fee schedule. Accordingly, providers, physicians and other suppliers would not be permitted to bill the Medicare Set-aside more than the State’s workers’ compensation fee schedule rate. For example, if a provider’s full charge for a particular service is $100 and the workers’ compensation carrier normally pays $65 for that particula
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