What Is Mandatory Claims Submission? Medicare Rule for Clinics
Mandatory claims submission is the Medicare rule, from Section 1848(g)(4) of the Social Security Act, that providers must submit claims to Medicare for covered services given to Medicare patients and cannot charge them for filing.
Mandatory claims submission is the rule that you file the Medicare claim for a Medicare patient's covered services, rather than leaving it to the patient. CMS guidance says Section 1848(g)(4) "requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990" (HHS/CMS). This is the rule that trips up cash PT and chiropractic owners who assume they can treat a 70-year-old for cash like anyone else. A chiropractor adjusting a Medicare patient for an acute low back flare is giving a covered service, so a claim has to go in.
Who does mandatory claims submission apply to?
It applies to physicians and suppliers furnishing covered services to Medicare beneficiaries, which includes physical therapists and chiropractors. The reason it bites these two groups hardest is that neither can step outside Medicare: CMS lists both under "Providers NOT Eligible to Opt Out" (CMS). A physician who opts out can privately contract with Medicare patients; a PT or chiropractor cannot. So a cash clinic either avoids seeing Medicare patients for covered services, enrolls and bills them properly, or works out a compliant setup with a healthcare attorney. Our guide to Medicare and cash-based physical therapy lays out those options.
What are the exceptions?
Noridian, a Medicare contractor, lists situations where you do not have to file. They include non-covered services (unless the patient asks you to submit a claim), cases where a beneficiary notice of noncoverage was signed, services outside the U.S., some secondary-payer situations, and providers who are excluded or have opted out (Noridian). Non-covered is the one cash clinics use most, for example wellness or performance work Medicare does not cover. For chiropractic maintenance care, the ABN is the tool that documents the patient's choice.
What are the deadline and the penalties?
CMS says claims "must be received by your Medicare contractor no later than one calendar year (12 months)" from the date of service (CMS). Noridian notes that providers may not charge patients for preparing or filing the claim, and that violations can bring civil monetary penalties per violation and possible exclusion from Medicare (Noridian). Chiropractors weighing a full exit should also read should chiropractors drop insurance.
This is general information, not legal or billing advice; check your state board and a healthcare attorney before you change how you bill.
Questions owners ask
Can a cash-based PT just skip billing Medicare?
Not for covered services to Medicare patients. CMS does not let physical therapists or chiropractors opt out, and mandatory claims submission requires filing for those services, with limited exceptions such as non-covered services the patient does not want billed.
How long do I have to submit a Medicare claim?
CMS says claims must be received by your Medicare contractor no later than one calendar year (12 months) from the date of service, or they will be denied.
Do I have to accept assignment if I file the claim?
No. CMS and Noridian both note that the filing requirement is separate from accepting assignment.