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Medicare and AHCCCS have requirements that may affect a provider’s policy for assessing missed appointment fees to the beneficiaries of those programs.

Medicare policy prohibits charging Medicare beneficiaries for covered services other than the applicable deductible and coinsurance amounts. CMS took the position that missed appointment fees are not charges for covered services but are instead charges for missed business opportunities. CMS nevertheless requires that Part B suppliers, including physicians, can charge beneficiaries a missed appointment fee so long as the fee is assessed equally against all patients, including non-Medicare beneficiaries. There is no restriction on the amount that may be assessed.

AHCCCS is a different story. The Federal government has placed significant restrictions on a provider’s ability to assess fees for missed appointments, notwithstanding A.R.S. § 36-2930.01, which permits providers to assess a $25 fee for missed appointments. As part of the Section 1115 Waiver, under which AHCCCS operates, the Federal government permits a missed appointment fee to be charged subject to several restrictions, including the following:

1. The fee is no greater than $3;
2. The provider must submit a policy to AHCCCS for approval prior to assessing the fee;
3. The provider must notify the beneficiary of the policy on an annual basis;
4. The provider must have a policy of notifying the beneficiary of upcoming appointments;
5. The fee may be assessed only against beneficiaries that live outside of Maricopa and Pima counties;
6. Providers must notifying AHCCCS beneficiaries, on an annual basis, of the fee related policies; and
7. The provider must keep an accounting of occasions the fee is assessed.

The government could argue that failure to comply with these restrictions is a violation of the Provider Agreement with AHCCCS. The Federal government’s approval for assessing the fee must be renewed again prior to January 1, 2013. If the policy is not renewed, then the assessment of a fee for late appointments would be a violation of Medicaid regulations.

For more information on missed appointment fees for Medicare, click here (See Section 30.3.13).