June 16, 2009 Features

Medicare Reimbursement Warnings

Two "Heads-Up" Scenarios

With the July 1 change in speech-language pathologists' ability to bill Medicare for services provided, all speech-language pathologists in private practice need to be aware of two critical new reimbursement scenarios.

Scenario 1: You provide services to a patient who is covered under Medicare but who pays out-of-pocket for treatment. After July 1 you may no longer provide services to this patient.

An SLP who is not a Medicare supplier may treat a Medicare beneficiary if the Medicare beneficiary signs a statement requesting that the SLP not submit a Medicare claim from the current date through a specific future date. If the SLP does not plan to enroll as a Medicare supplier/provider, the SLP should not treat the patient until such an agreement has been signed. If an agreement is not signed and services are rendered, the SLP is required to enroll as a Medicare supplier. Because a supplier is not required to submit a claim based on the aforementioned agreement, the SLP is excluded from limits on charges or the annual therapy cap for Medicare covered services. 

Caveat: You may collect out-of-pocket payment from Medicare beneficiaries who seek services that are not covered by Medicare, such as patients who have exceeded their therapy caps and do not qualify for an exemption or patients seeking help for non-reimbursable services such as voice quality and accent modification.

Scenario 2: You are an employee or contractor of a physician or physician group and you are not enrolled as a Medicare supplier as of July 1. You are subject to restrictions in your care of Medicare beneficiaries.

SLPs who do not enroll as providers remain subject to the "incident to physicians' services" rules:

  • A physician must be in the office suite when the SLP renders services
  • A group physician must be managing the patient (i.e., services cannot be limited to SLP services only)
  • The physician's National Provider Identification (NPI) number (used for Medicare billing) is entered for each procedure code billed If you enroll as a Medicare provider, none of these restrictions apply. You enter your own NPI for each procedure code billed.

For information on how to enroll in Medicare as a private practitioner, go to the ASHA Web site. Direct specific questions to reimbursement@asha.org.

Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.

cite as: Kander, M. (2009, June 16). Medicare Reimbursement Warnings : Two "Heads-Up" Scenarios. The ASHA Leader.


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