August 31, 2010 Bottom Line

Medicare Rules and University Clinics

Medicare reimbursement rules for university speech and hearing clinics can be confusing. As of a year ago, Medicare requires all speech-language pathologists in private practice and non-hospital-based clinics who provide treatment to Medicare-eligible patients to enroll as Medicare providers. The following questions and answers should help clarify this issue as it relates to university clinics.

For more information, visit the reimbursement section of ASHA's website.

Q: Why do Medicare rules that govern private-practice SLPs affect fee-for-services university clinics?

According to the Centers for Medicare and Medicaid Services (CMS), Medicare is reimbursing the clinic for the services of a qualified SLP; therefore, even though the SLP would almost always assign payments to the clinic, the SLP must be enrolled as a provider.

Q: Can Medicare payments go to the clinic and not to the SLP?

Yes. Even though a university clinic is not a provider enrolled in Medicare, each enrolled SLP employee or contractor can designate that all payments be assigned to the clinic. This designation is accomplished by submitting form CMS-855R, Reassignment of Medicare Benefits [PDF].

Q: May clinics choose not to accept Medicare beneficiaries? If so, does that choice require a specific type of notice?

Clinics may choose not to accept Medicare beneficiaries, and no specific type of notice is required.

Q: Are all SLPs required to obtain National Provider Identifier (NPI) numbers and Medicare numbers?

Federal law requires the NPI for those who directly bill electronically. However, NPI numbers for a group practice or clinic and practitioners can be required by a payer (such as Medicare or a private health plan) or facility employer. If a clinic does not accept Medicare patients, an SLP’s enrollment as a Medicare provider is optional.

Q: Do university clinics and/or clinic supervisors need to obtain an NPI number?

Because some payers require the NPI, a university clinic should apply for a group NPI (i.e., Level II). Practitioners need an individual NPI to enroll in Medicare, but other payers may or may not require the individual NPIs.

Q: If a university clinic does not bill private insurance, Medicaid, or Medicare, can it continue to bill patients directly and not bill Medicare—even if the person is a Medicare beneficiary?

ASHA has received confirmation from CMS that free clinics (i.e., clinics that never charge for services) are exempt from Medicare enrollment requirements.

If the clinic charges for services, SLPs may treat Medicare beneficiaries only if they are enrolled as Medicare providers. There is an exception: If a beneficiary, of his or her own free will, instructs a practitioner not to submit a claim to Medicare, the practitioner may treat the patient outside of Medicare. However, there are two significant complications:

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.

Q: If a university clinic bills Medicare, is it always Part B?

Yes. Part B is for outpatient services.

Q: If a university clinic bills Medicare, what are the student supervision requirements?

Supervision of students under Medicare requires a qualified SLP to direct the service in the room at all times and not engage in other activities. "Line of site" supervision allows more flexibility but applies only to skilled nursing facility residents who are under Medicare Part A.

Q: Do private insurance companies follow Medicare regulations?

Private health plans adopt Medicare coverage policies selectively. All private plans require that services be rendered by a qualified health care practitioner and rarely reimburse for student involvement. Informing a third-party payer of the degree of student supervision will prevent a future audit that could demand thousands of dollars in repayment.

Q: Our clinical faculty are not Medicare suppliers and we provide a 100% discount to the clients who are Medicare beneficiaries: Can we still see the clients?

Only if all services are free to all clients.

Q: Is a clinic serving Medicare patients required to bill electronically?

Medicare policies state that hard-copy submission is allowed by practitioners or suppliers who have fewer than 10 full-time employees. The regional Medicare payer will need to determine the boundaries of a university clinic, based on its organizational structure, to determine the number of employees that are included.  

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

cite as: Kander, M. (2010, August 31). Medicare Rules and University Clinics. The ASHA Leader.

  

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