University clinics are adjusting to the new billing environment in which private-practice speech-language pathologists now may enroll as Medicare suppliers. University clinic directors want to know how clinics can continue to treat Medicare beneficiaries appropriately and comply with federal regulations. For example, how can a clinic provide services to Medicare beneficiaries but continue with its current fee structure?
Officials from the Centers for Medicare and Medicaid Services (CMS) recently indicated that "unqualified staff" is an acceptable reason for not submitting a claim to Medicare because such services are not covered. This reason would apply if there is not the CMS-required 100% supervision of students providing treatment, a supervision level much higher than the ASHA standard. The Medicare supervision requirement specifies that a qualified SLP be in the room directing the student and not engaged in other activities.
Unless clinic services are totally free, a Medicare beneficiary has the right to request that the clinic submit a claim, even though coverage is likely to be denied. Such requests should be rare, assuming beneficiaries are informed that claim denial is a virtual certainty. However, if a beneficiary insists that the claim be submitted and there is no opportunity to refer the patient to another provider or elsewhere in the university health care system, claim submission requires that the SLP/audiologist enroll as a Medicare provider.
If some or all of the clinic SLPs or audiologists decide to enroll in Medicare, however, their provider status need not affect clinic operations. That is, a university clinic does not need to modify its practices (such as providing 100% student supervision or obtaining physician certification of a plan of care) to comply with Medicare policies if it is not seeking Medicare coverage for its services.
The following Medicare policies should be of interest to clinic managers.
Advance Beneficiary Notice of Non-coverage
The Advance Beneficiary Notice of Non-coverage (ABN), a one-page CMS form, is used to inform the patient that coverage is likely to be denied. CMS designed the ABN for use by Medicare providers and suppliers, but it also may be used by clinicians who are not Medicare-enrolled. The form explains why Medicare may not pay for the services and requires the beneficiary to choose one of three options:
- The client agrees to pay for the services but requests that a claim be submitted and acknowledges responsibility for payment if Medicare does not pay.
- The client agrees to receive the services but does not request that a claim be submitted.
- The client decides not to receive the services.
Use of the ABN form is voluntary; clinics may devise their own form.
When services are free, there is no requirement to submit a claim for a Medicare beneficiary even if requested to do so, and there is also no requirement to enroll in Medicare. The advantages of providing free services includes the elimination of paperwork for filing claims at the patient's request and enrolling as a Medicare supplier in order to submit a claim. If considering free status only for Medicare beneficiaries, clinics may want to determine if state or local laws require services for all patient groups to be free.
In setting fees, including sliding fee schedules based on income, the clinic is not bound by Medicare restrictions for services not covered by Medicare.
The clinic may wish to evaluate each Medicare beneficiary to determine if the beneficiary may be better served by other providers or other health service units at the university. The alternative sites may seek Medicare reimbursement if the patient meets basic coverage rules for speech-language treatment, which include the prediction of significant progress reaching functional communication goals ("significant" defined as a generally measurable and substantial increase in the patient's level of communication and independence compared to the level at the initiation of treatment).
Covered audiology services require a physician order for testing that is for the purpose of helping the physician diagnose or otherwise manage the patient and that is not related to a hearing aid evaluation or fitting.
Claims for Non-covered Services
After being advised that the services are not covered (due to unqualified staff), a Medicare beneficiary may still demand that the clinic submit a claim. If the clinic is not enrolled, it must first enroll and then submit the claim. On the claim form, a special modifier, GY, should be inserted after the CPT procedure code (and after the GN modifier denoting SLP services). This modifier indicates that the service, as defined, is never a Medicare benefit. As with any Medicare claim, documentation that supports coverage or noncoverage is not sent to the Medicare contractor unless requested after the claim is received.
Faculty Medicare Enrollment
If a beneficiary demands that a claim be submitted, CMS advises that faculty SLPs and/or audiologists enroll as a group practice. To do so, each practitioner completes the individual application (Form 855i) and a Form 855R that reassigns payment to the group practice. The group is enrolled by Form 855B. Legal counsel should determine the appropriate way in which funds from the group (if any) are transferred to the university. CMS officials state that the transfer of funds can be accomplished by a bank account, in the name of the group, which is accessible directly by the university. However, in situations in which there are no covered services and any claims submitted are at the request of the beneficiary, there would seem to be no funds to distribute.
For more information, visit the ASHA Web site. The information includes a table of issues and explanations as well as FAQs.