Regulations for Paying Medicare Referral Fees
- Medicare programs have strict regulations regarding referral fees.Jupiterimages/Photos.com/Getty Images
A person may get a referral from a physician to see a specialist who is able to further diagnose medical conditions but at a cost that the person, or Medicare, had not anticipated. Medicare beneficiaries need to be aware of the different types of benefit rules regarding referral payments, while Medicare providers must follow certain regulations to avoid illegal use of referrals. - Different Medicare plans will provide coverage payments for referrals made by your primary doctor. Medicare Part B will cover referrals for abdominal aortic aneurysms screenings, physical exams and pulmonary rehabilitation. The original Medicare is a fee-for-service coverage for referrals.
- A Medicare beneficiary should review their health plan rules before a physician refers him to a specialist for additional evaluation or treatment. Depending upon the plan rules, the person may be able to go to a specialist without getting a referral request but the service provider must be enrolled in Medicare. Otherwise, the patient will be obligated to pay out-of-pocket expenses for the referral.
- Since Medicare beneficiaries have a choice in healthcare providers, the Office of the Inspector General has observed the practice of referral kickbacks. Home health providers have offered kickbacks to physicians, hospitals and rest homes in exchange for a referral of services payable by Medicare. Anti-kickback statutes prohibit referral fees disguised as salaries when there have been no health service given, when services have been charged at higher than fair market value, or when free services have been given to retirement homes in return for referrals from home health providers.