Can I Charge This Fee? The Test Before Any New Patient Charge

What are the four questions?

Any fee a solo practice charges a patient has to clear four questions, in order. Is the thing you are charging for already paid for by the patient's plan? Does that payer's rule or contract let you bill the patient for it? Does your state cap or ban the charge? Did the patient agree to it in writing before it came due? A fee that fails any one of the four stays off the schedule.

The order matters because each question closes off a class of fees before the next one is worth asking. The first knocks out the annual administrative fee that bundles work Medicare already pays for. The second decides the no-show fee for a Medicaid patient. The third caps the records fee. The fourth is the one a practice controls entirely, and the one most often skipped.

Two of the four vary by state. Records-copy caps sit in state health codes underneath the federal ceiling, and whether a Medicaid patient can be charged for a missed visit is a question for each state's Medicaid agency, because the federal rule sets only the floor. Where a state figure appears below, it is labeled with its state and paired with the lookup for yours, and no single state's answer stands in for the country's.

Keep the four questions next to your fee schedule and run them before a line is added, whatever the fee is called.

Is the work already covered by the patient's plan?

If the plan already pays for the work, the patient cannot be charged for it a second time, and under Medicare and Medicaid that is a program rule with sanctions behind it rather than a contract term. A practitioner who accepted Medicare assignment may charge a beneficiary only the deductible and coinsurance on a covered service, plus the price of items and services Medicare does not cover at all 1Ref 1Office of Inspector General, U.S. Department of Health and Human Services (2004).OIG Alerts Physicians About Added Charges for Covered Services.The Medicare covered-versus-non-covered fork: a practitioner who accepted assignment may charge a beneficiary only the deductible and coinsurance on a covered service plus non-covered items, the $600 annual contract example whose bundled items OIG alleged were already covered, and the exposure to substantial penalties and exclusion..

The example OIG chose for its 2004 alert is the one solo practices keep reinventing. A physician offered patients a $600 annual 'Personal Health Care Medical Care Contract' covering care coordination, a comprehensive assessment and extra time, and OIG alleged that at least some of those services were already covered and reimbursable by Medicare, making each contract a request for payment for covered work. The physician settled, and OIG's standing warning is that such a request exposes a participating provider to substantial penalties and exclusion 1Ref 1Office of Inspector General, U.S. Department of Health and Human Services (2004).OIG Alerts Physicians About Added Charges for Covered Services.The Medicare covered-versus-non-covered fork: a practitioner who accepted assignment may charge a beneficiary only the deductible and coinsurance on a covered service plus non-covered items, the $600 annual contract example whose bundled items OIG alleged were already covered, and the exposure to substantial penalties and exclusion.. What mattered was whether anything inside the bundle was work Medicare pays for, whatever the fee was called. A retainer fee without opting out of Medicare survives only for what sits entirely outside the covered benefit.

Medicaid draws the line harder.

A state plan must limit participation to providers who accept, as payment in full, the amount the agency pays plus whatever deductible, coinsurance or copayment the plan itself requires of the patient 2Ref 2Centers for Medicare & Medicaid Services (2013).§ 447.15 Acceptance of State payment as payment in full..The federal Medicaid payment-in-full rule for participating providers, its silence on missed-visit charges (which leaves that question to each state plan), and that a patient's inability to pay does not eliminate liability for plan-required cost sharing.. For a covered service there is nothing left to bill. The rule adds one line worth reading twice: a patient's inability to pay the cost sharing does not eliminate their liability for it 2Ref 2Centers for Medicare & Medicaid Services (2013).§ 447.15 Acceptance of State payment as payment in full..The federal Medicaid payment-in-full rule for participating providers, its silence on missed-visit charges (which leaves that question to each state plan), and that a patient's inability to pay does not eliminate liability for plan-required cost sharing.. But that is the plan's cost sharing, set by the plan, and it is the only patient charge the rule contemplates.

Commercial plans put the same fork in a private document. A participation agreement typically has a section on what a member may be billed, and since the answer differs by contract, the lookup is the contract itself. The first question passes when the practice is out of network, or when the patient is paying cash for a service no plan will be billed for. Then the fourth, the written estimate, becomes the one doing the work.

Can you charge for a missed visit or a form?

For Medicare patients, yes on missed visits, with one condition. CMS allows a practice to charge beneficiaries for a missed appointment as long as the same policy and the same amount apply to every patient, Medicare or not. The charge is for a missed business opportunity rather than for a service, Medicare pays nothing toward it, and it should not be billed to Medicare 3Ref 3Centers for Medicare & Medicaid Services (2024).Medicare Claims Processing Manual, Chapter 1 — General Billing Requirements (CMS Pub. 100-04).Chapter 1 section 30.3.13 only: a practice may charge Medicare beneficiaries for missed appointments when the same policy and amount apply to non-Medicare patients, the charge is for a missed business opportunity rather than a service, and Medicare pays nothing toward it and it is not billed to Medicare..

The manual settles the two things solo practices argue about. What the practice charges Medicare beneficiaries for missed appointments must be the same as what it charges non-Medicare patients, whatever that amount may be 3Ref 3Centers for Medicare & Medicaid Services (2024).Medicare Claims Processing Manual, Chapter 1 — General Billing Requirements (CMS Pub. 100-04).Chapter 1 section 30.3.13 only: a practice may charge Medicare beneficiaries for missed appointments when the same policy and amount apply to non-Medicare patients, the charge is for a missed business opportunity rather than a service, and Medicare pays nothing toward it and it is not billed to Medicare.. But that cuts both ways: a lower no-show fee for Medicare patients fails the rule as surely as a higher one. The charge itself goes to the patient directly rather than onto a claim.

Medicaid answers the same question one state at a time. The federal payment-in-full rule sets what a participating provider accepts for a covered service and says nothing about missed visits 2Ref 2Centers for Medicare & Medicaid Services (2013).§ 447.15 Acceptance of State payment as payment in full..The federal Medicaid payment-in-full rule for participating providers, its silence on missed-visit charges (which leaves that question to each state plan), and that a patient's inability to pay does not eliminate liability for plan-required cost sharing., so the question of the no-show fee and Medicaid patients goes to the state Medicaid agency's provider manual. Look for the section on billing beneficiaries or cost sharing. If a Medicaid patient no-showed before that section was read, hold the charge until it has been.

Forms sit on the other side of the first question. Completing an FMLA certification or a disability form is, in most cases, work no plan pays for, and many practices charge for it as a non-covered service. No source on this page prices it, so no dollar figure appears here. Fees for FMLA and disability forms still have to clear the third and fourth questions, and the signed policy has to exist before the form arrives.

Does your state cap or ban the fee?

Sometimes, and the records-copy fee is the clearest case. HIPAA sets the ceiling. A covered entity may charge a reasonable, cost-based fee for a copy of the record, and the fee may include only four costs: labor for copying, supplies for a paper copy or the portable media the patient asked for, postage when the patient asked for mailing, and preparing a summary or explanation the patient agreed to 4Ref 4Department of Health and Human Services (2024).§ 164.524 Access of individuals to protected health information..The reasonable, cost-based records-copy fee under paragraph (c)(4) and the closed list of four cost components it may include; no dollar figure is drawn from it.. Time spent finding the chart is not on the list.

States can cut underneath that ceiling, and one state's number is only that state's number. California's Health and Safety Code section 123110 caps the copying charge at twenty-five cents per page for paper copies and fifty cents per page for records copied from microfilm, requires that a patient be allowed to inspect the record within five working days of the request, and requires copies to go out within 15 days 5Ref 5California State Legislature (2024).California Health and Safety Code Section 123110.California only, as the worked example of a state cap under the HIPAA ceiling: the per-page copying limits, the five-working-day inspection clock and the 15-day copy clock.. A California practice charging a flat retrieval fee fails both the federal list and the state cap. A practice anywhere else needs its own state's section, because the federal list is a ceiling and a state is free to cap it lower.

The lookup is short. Search your state's health or medical-records statute for 'per page' or 'reasonable cost', read your licensing board's rules on fees and advertising, and read the cost-sharing section of your state Medicaid manual. Those three places are where a state's rules on patient fees tend to sit, and a rule found in any of them wins over a fee already printed on the schedule.

Interest on an unpaid balance is a separate question, and nothing cited on this page answers it. A finance charge stays off the schedule until the state's own rule has been read.

Did the patient agree in writing before the charge came due?

A fee the patient never agreed to is a dispute whatever the payer rules say, and for self-pay work the written agreement is a federal requirement with a clock. A practice must give an uninsured or self-pay patient a written good faith estimate of expected charges when the visit is scheduled or when the patient asks, and self-pay includes an insured patient who does not want a claim submitted to their plan 6Ref 6U.S. Department of Health and Human Services / Centers for Medicare & Medicaid Services (Code of Federal Regulations, Title 45) (2023).§149.610 Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals.The written good faith estimate owed to an uninsured or self-pay patient, the definition that includes an insured patient who does not want a claim submitted, and the one- and three-business-day timing tiers..

The clocks are specific. When a service is scheduled at least three business days ahead, the estimate is due no later than one business day after scheduling. When it is scheduled at least ten business days ahead, it is due no later than three business days after scheduling. When a patient asks for one without scheduling, it is due within three business days of the request 6Ref 6U.S. Department of Health and Human Services / Centers for Medicare & Medicaid Services (Code of Federal Regulations, Title 45) (2023).§149.610 Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals.The written good faith estimate owed to an uninsured or self-pay patient, the definition that includes an insured patient who does not want a claim submitted, and the one- and three-business-day timing tiers.. A cash-pay practice that books next week's intake and sends the estimate the same afternoon has met all three.

The estimate covers the expected charges for the service. The fee policy covers everything around it: the no-show and late-cancel amount, the records fee, the form fee, and what happens to an unpaid balance. Those belong in the intake paperwork signed on the first day, before any of them can be triggered. The rule for waiving the late-cancel fee belongs there too, decided once, so that a cancellation that arrives as "I was sick" is handled by the policy and not by whoever happens to read the message that morning.

For counselors, the profession's code writes the same requirement down. The 2014 ACA Code of Ethics requires counselors to explain the nature of all services provided (A.2.b), to consider the client's financial status and locality when establishing fees, and to adjust a fee that creates undue hardship where legally permissible (A.10.c). Counselors who intend to use a collection agency or legal measures for unpaid fees have to say so in the informed consent documents and give the client timely notice before acting (A.10.d) 7Ref 7American Counseling Association (2014).2014 ACA Code of Ethics.Counselor ethics on fees for ACA-governed clinicians: A.2.b explaining the nature of services, A.10.b fee splitting, A.10.c hardship adjustment when establishing fees, and A.10.d disclosing collection-agency or legal collection intent in informed consent; ethics for members, not law, and no dollar figure.. Fee splitting and referral commissions are prohibited at A.10.b 7Ref 7American Counseling Association (2014).2014 ACA Code of Ethics.Counselor ethics on fees for ACA-governed clinicians: A.2.b explaining the nature of services, A.10.b fee splitting, A.10.c hardship adjustment when establishing fees, and A.10.d disclosing collection-agency or legal collection intent in informed consent; ethics for members, not law, and no dollar figure.. The code binds ACA members and sets no dollar figure. Social workers, marriage and family therapists, psychologists and nurses answer to their own codes and boards, which were not checked for this page.

Can you charge less?

Yes, within limits, and for a Medicare patient, charging less is the more regulated direction. Routinely waiving Part B copayments and deductibles is prohibited. Forgiving a copayment for one patient's financial hardship is allowed. But that exception must not be used routinely; it is for occasional, individual need, and the practice is otherwise expected to make a good-faith effort to collect what the patient owes 8Ref 8U.S. Department of Health and Human Services, Office of Inspector General (1994).Routine Waiver of Part B Co-payments/Deductibles.The Medicare Part B side of charging less: routine waiver of copayments and deductibles is prohibited, the occasional individual financial-hardship exception, the expected good-faith collection effort, and the advertising phrasings OIG lists as evidence of routine waiver. Not used for penalty amounts..

The 1994 alert lists what OIG reads as evidence of a routine waiver, and two of the items are ordinary marketing. Advertisements stating 'Medicare Accepted As Payment In Full,' 'Insurance Accepted As Payment In Full,' or 'No Out-Of-Pocket Expense' are on the list, and so are advertisements promising discounts to Medicare beneficiaries 8Ref 8U.S. Department of Health and Human Services, Office of Inspector General (1994).Routine Waiver of Part B Co-payments/Deductibles.The Medicare Part B side of charging less: routine waiver of copayments and deductibles is prohibited, the occasional individual financial-hardship exception, the expected good-faith collection effort, and the advertising phrasings OIG lists as evidence of routine waiver. Not used for penalty amounts.. A practice website that promises to accept insurance as full payment has published the evidence itself. The alert is three decades old and its principle has held; it is not a source for current penalty amounts, and none appear here.

The hardship exception works when it is documented as one.

A note in the account separates an occasional hardship decision from a discount policy under another name. Make it at the time, and name the patient's circumstances and the amount forgiven. The counselor's code points the same way from the ethics side: a fee that creates undue hardship may be adjusted for that client, where legally permissible 7Ref 7American Counseling Association (2014).2014 ACA Code of Ethics.Counselor ethics on fees for ACA-governed clinicians: A.2.b explaining the nature of services, A.10.b fee splitting, A.10.c hardship adjustment when establishing fees, and A.10.d disclosing collection-agency or legal collection intent in informed consent; ethics for members, not law, and no dollar figure..

Medicaid leaves less room in either direction. The cost sharing is the plan's, the liability for it stays with the patient whether or not they can pay 2Ref 2Centers for Medicare & Medicaid Services (2013).§ 447.15 Acceptance of State payment as payment in full..The federal Medicaid payment-in-full rule for participating providers, its silence on missed-visit charges (which leaves that question to each state plan), and that a patient's inability to pay does not eliminate liability for plan-required cost sharing., and a practice that waives Medicaid copayments as a policy is rewriting a program rule on its own.

Run the four questions on the fees solo practices add most

The fees below are the ones solo practices add most often, run through the four questions with the source that answers each. Where a cell says state or contract, no national rule exists and the lookup is the answer. Where a cell names a rule, its citation is the thing to read before the fee goes on the schedule. No row carries a dollar amount, because no source on this page sets one.

Counsel earns its fee at two points in this table: a commercial contract whose patient-billing section can be read two ways, and any charge to a Medicare patient that touches a covered service. The rest is reading. The four questions tell you which fees the law and the contract leave open; whether to charge them, and at what amount, is a business decision to make with your own numbers.