New regulations allowing private-practice speech-language pathologists to bill Medicare directly for services provided to beneficiaries—hailed as a victory for establishing parity with other private-practice health care professionals—have raised some unanticipated concerns for practitioners in certain settings. These concerns center on regulations that prohibit SLPs from providing services to Medicare beneficiaries who pay out-of-pocket for their treatment.
As approved providers, SLPs may not receive out-of-pocket payment for covered services from Medicare beneficiaries (excluding their 20% copayment). In general, physicians and other suppliers are required by law to submit claims on behalf of beneficiaries and must enroll in the Medicare program in order to do so. However, a provision allows physicians and certain other practitioners to "opt out" of the Medicare program and receive private payment for services to Medicare beneficiaries. SLPs (and occupational and physical therapists) are excluded from this provision and may not opt out of Medicare enrollment. University clinics, private practitioners, and community centers with private-pay clients who are Medicare beneficiaries are affected by these regulations.
SLPs—even those not planning to enroll as Medicare providers—must be aware of the following Medicare rules:
- Mandatory claim submission. If a Medicare beneficiary requests that a claim be submitted to Medicare, the practitioner must do so. The beneficiary's request can be based on the belief that a service may be covered or simply a desire for a formal Medicare determination of coverage. If the practitioner has not already enrolled as a Medicare provider, he or she must enroll to submit the claim. Violations of the mandatory submission rule may result in a civil penalty of up to $2,000 for each violation.
- Mandatory claim submission exception. A beneficiary may refuse to allow a claim to be submitted to Medicare. If all of a practitioner's Medicare clients make this demand, the SLP or clinic is relieved of the Medicare enrollment requirement. Two factors may complicate a clinician's efforts to circumvent the mandatory claims submission regulation:
- All beneficiaries must make this demand truly of their own free will.
- A beneficiary is free to change his or her decision at any time and request that a claim be submitted to Medicare for current and/or past services.
- Application to fee-for-service university clinics. Some university clinics have had the misconception that Medicare private-practice regulations do not apply to them; they are, however, subject to the rules. The Centers for Medicare and Medicaid Services (CMS) explains that Medicare is reimbursing the clinic for the services of a qualified SLP; therefore, the SLP must be enrolled as a provider (even though the SLP would almost always assign payments to the clinic).
- As is the case for all Medicare providers and suppliers, students providing services require 100% supervision (i.e., a qualified SLP must be in the room and not engaged in other activities).
- University clinics may sometimes provide services that are not reimbursable (i.e., do not require the skills of a qualified SLP or do not result in significant functional progress). Even though these services are not covered by Medicare, the provider is not necessarily sheltered from certain Medicare regulations, such as mandatory claim submission. If the clinician anticipates that the claim will be denied, the provider should require the patient to sign an advance beneficiary notice (ABN) that assigns financial responsibility for unreimbursed services to the patient.
- Application to free university clinics. ASHA has received confirmation from CMS that free clinics (i.e., that never charge for services) are exempt from Medicare enrollment requirements. Medicare regulations state that reimbursement for a service is equal to the lower of two amounts: the provider's charge or the Medicare fee schedule amount. Thus, free clinics are not required to enroll because no payment would be made for claims.
- Annual therapy cap. SLPs treating Medicare patients who have exceeded the $1,840 cap for combined speech-language and physical therapy services must still abide by the mandatory claim submission rules. ASHA has determined that exceeding the cap does not automatically exclude speech-language services from Medicare coverage because of the exceptions process that allows for coverage of "medically necessary" services beyond the cap.
Because of these rules designed to protect Medicare beneficiaries, clinicians who do not want to enroll as Medicare providers should not evaluate or treat any Medicare beneficiaries. Most individuals age 65 and over are beneficiaries, as are those with severe disabilities who have received Social Security disability income payments for at least 30 months.
For more information, visit the ASHA Web site.