Which term describes the action of charging a Medicare beneficiary more than the reimbursement rate?

Which term describes the action of charging a Medicare beneficiary more than the reimbursement rate?

• A. Balance Billing
• B. Claim
• C. Concealment
• D. Formulary

Answer: (A)

Balance billing describes charging a Medicare beneficiary the difference between the provider’s usual charge and the amount Medicare reimburses. When a provider accepts Medicare, they’re expected to accept Medicare’s approved amount and patient cost-sharing; asking the patient to pay more than that amount is balance billing. This concept is central to detecting improper charges in Medicare, which is a common area of fraud, waste, and abuse investigations. The other terms don’t describe this practice: a claim is simply a request for payment, concealment means hiding information to mislead, and a formulary is a list of medications covered by a plan.

Balance billing describes charging a Medicare beneficiary the difference between the provider’s usual charge and the amount Medicare reimburses. When a provider accepts Medicare, they’re expected to accept Medicare’s approved amount and patient cost-sharing; asking the patient to pay more than that amount is balance billing. This concept is central to detecting improper charges in Medicare, which is a common area of fraud, waste, and abuse investigations. The other terms don’t describe this practice: a claim is simply a request for payment, concealment means hiding information to mislead, and a formulary is a list of medications covered by a plan.