Pop Quiz…


Question #1: Your mother is visiting you one weekend evening. She slips in your house. She now has a giant gash in her arm which requires stitches. Neither of you are enthused about spending the evening in an ER when you are fully competent to sew it up. Further, you will document the encounter and keep a record, as required by your Board of Medicine.


Side distraction. Every state has different policies vis a vis treating family members. This blog post doesn’t touch on that topic. And, in this blog post, it is reasonably assumed that your judgment will not be clouded by your emotional attachment to a family member.


Now that Mom is all sewn up, can you send a claim to Medicare?


(Also, assume that you would have asked your Mom to pay any copay or co-insurance which would have been owed by a similarly situation non-relative. Really.)


Answer: No.


Medicare has list of claims that are excluded. One such section is called- Charges Imposed by Immediate Relatives of the Patient or Members of the Patient’s Household

A3-3161, HO-260.12, B3-2332


“These are expenses that constitute charges by immediate relatives of the beneficiary or by members of their household. The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously.”


OK. Who’s considered a family member?


Actually lots of people:


The following degrees of relationship are included within the definition of immediate relative.

  • Husband and wife;
  • Natural or adoptive parent, child, and sibling;
  • Stepparent, stepchild, stepbrother, and stepsister;
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
  • Grandparent and grandchild; and
  • Spouse of grandparent and grandchild.


And regarding in-laws. Divorce or death changes nothing.


“A step-relationship and an in-law relationship continues to exist even if the marriage upon which the relationship is based is terminated through divorce or through the death of one of the parties.”


Oh. And Medicare’s list isn’t confined to the traditional list of relatives.


It includes “domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.” This would include your live-in nanny.


Question #2: Your mother is visiting you. She develops acute cholecystitis. (Yes, I know. She’s had a rough week.) There’s a stone obstructing the cystic duct and it appears she’ll need surgery. You trust your partner, an excellent laparoscopic surgeon, to perform the procedure. He’s flattered you trust him to care for your mother. Mom does great. Can your partner bill Medicare? Again, assume that any co-pay and co-insurance is billed and collected as with any other patient.


Answer: No.




“Payment is not made under Part A or Part B for items and services furnished by providers to immediate relatives of the owner(s) of the providers. This exclusion applies whether the provider is a sole proprietor who has an excluded relationship to the patient, or a partnership in which even one of the partners is related to the patient.”


Yep, that’s a head scratcher. Presumably, Medicare assumes your partner would provide “gratuitous” services to your family. Perhaps he would. But, if Medicare mandates this assumption as a rule, it does not sound like a “gift”, but an obligation.


Finally, demonstrating that Medicare keeps up with evolving issues across the US, Medicare has an updated policy addressing doctors submitting claims for treatment performed on same-sex spouse.

In United States v. Windsor, 570 U.S. __, 113 S. Ct. 2675 (2013), the Supreme Court ruled that section 3 of the Defense of Marriage Act is unconstitutional. In light of this decision, the Department has instituted a policy of treating same-sex marriages on the same terms as opposite-sex marriages to the greatest extent reasonably possible. This FAQ clarifies Windsor’s application to the exclusion authority under section 1128(b)(8) of the SSA. Effective June 26, 2013, the date of the Windsor decision, same-sex spouses and family members that result from same-sex marriages meet the definition of “immediate family member” if the state or other jurisdiction, whether foreign or domestic, where the couple was married recognizes the marriage under its laws, or if the state(s) or other jurisdiction(s) where the couple lives recognizes the marriage as a legally valid marriage….

Final quiz question: If you perform a medical procedure on yourself, can you submit a claim to Medicare for your professional fee? I think the answer is obvious.