American Speech-Language-Hearing Association

Medicare and University Clinics Questions and Answers

The following questions were submitted by university clinic directors.

Why are fee-for-service university clinics subject to Medicare rules that govern private practice SLPs and audiologists?

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.)

Can a clinic serving Medicare patients ask that payments go to the clinic and not to the SLP or audiologist?

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

May clinics choose not to accept Medicare beneficiaries? Does that require any specific type of notice?

No specific type of notice is required. A sign can be posted in the clinic, "We Do Not Treat Medicare Beneficiaries." The sign might be more patient-friendly with a preface, "Due to Difficulty Adhering to Medicare Billing and Coverage Requirements."

Are all SLP's and audiologists required to obtain National Provider Identifier (NPI) numbers and Medicare numbers-or is it optional?

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 and audiologist's enrollment as a Medicare provider is optional.

Do university clinics need to obtain an NPI number? If so, can the clinic get a number or do the individual supervisors need them?

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

If a university clinic does not currently bill private insurance, Medicaid, or Medicare, can it continue to bill patients privately and not bill Medicare (even if the person is a Medicare beneficiary-often after having exhausted Medicare funds)?

ASHA has received confirmation from CMS that clinics that are free (i.e., never charge for services) are exempt from Medicare enrollment requirements. If not a free clinic, SLPs/OTs/PTs and audiologists may treat Medicare beneficiaries only if they are enrolled as Medicare providers. There is an exception: If a beneficiary, of their own free will, instructs a practitioner to not 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.

Regarding "exhausted Medicare funds," the annual therapy cap (combined SLP/PT services) has been largely circumvented by Congress because several years ago it established an "exceptions process" that allows coverage as long as documentation in the medical record clearly shows medically/functionally necessary services. ASHA has determined that exceeding the cap does not automatically exclude speech-language services from Medicare coverage because of the exceptions process that allows coverage of medically necessary services beyond the cap.

Can a university clinic bill Medicare beneficiaries directly if they have exceeded the annual therapy cap?

The annual therapy cap has been largely circumvented by Congress because several years ago it established an "exceptions process" that allows coverage as long as documentation in the medical record clearly shows medically/functionally necessary services. 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.

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

Yes. Part B is for outpatient services.

If a university clinic bills Medicare does student supervision have to be 100%?

Supervision of therapy students or audiology students under Medicare requires a qualified SLP or audiologist to be directing the service in the room and not engaged in other activities. The term "line of site" supervision allows a bit more flexibility but applies only to skilled nursing facility Part A residents.

Do private insurance companies follow Medicare regulations?

Private health plans selectively adopt Medicare coverage policies. All private plans require that services be rendered by a qualified health care practitioner. Rarely do they describe student involvement. It is wise to inform the third party payer of the degree of supervision of students. This will prevent a future audit that could demand thousands of dollars in repayment.

Can a non-Medicare clinic treat a Medicare beneficiary who has agreed in writing to bypass Medicare and pay out-of-pocket?

In order to treat Medicare beneficiaries, a practitioner must be enrolled as a Medicare provider. Practitioners who do not submit a claim to Medicare on behalf of a beneficiary for a covered Part B service within 1 year of providing the service, may be subject to civil monetary penalties under the Social Security Act (§§1848(g)(1) and/or 1848(g)(3)). Congress enacted these requirements for the protection of all Part B beneficiaries.

While the Medicare Benefit Policy Manual states that a beneficiary may refuse to allow a claim to be submitted to Medicare, 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 require that a claim be submitted to Medicare for current and/or past services.

ASHA has determined that such attempts to circumvent this rule are potentially subject to large fines and dependent on regional Medicare Administrative Contractor interpretation. Note that you can initiate the enrollment process the day you see the patient and your enrollment will be back-dated to the day of claim submission.

Clinicians have been confused by the term "opt out" of Medicare. SLPs cannot opt out. Congress has allowed physicians, physician assistants/nurse practitioners, psychologists, social workers, and dieticians to opt out. This allows the practitioner to establish an independent 2-year fee contract with each Medicare patient. However, for that practitioner, none of their patients can be reimbursed by Medicare.

Can a clinic that normally bills for Medicare services bill the patient directly for services if the submitted claim has been denied?

Yes, if the reason for the denial is that the type of service is never covered or the services are not medically necessary. Denials based on technical errors such as improper coding would not apply here. When there is reason to believe that the claim will be denied, be advised that an Advance Beneficiary Notice (ABN) should be signed by the beneficiary before the services are rendered so he/she understands there may be personal financial responsibility if Medicare is not responsible for payment.

If the clinical faculty do not become Medicare suppliers and we provide a 100% discount to the clients who are Medicare beneficiaries; Can we still see the clients?

Only if all clients are seen for free.

Do university clinics need to follow the Medicare student supervision rule (i.e., in the room all of the time and not engaged in other activities) if they provide a 100% discount to all Medicare beneficiaries?

If all clients (not just Medicare clients) are seen free, the clinic need not enroll in Medicare and thus need not follow the supervision rules.

If a non-Medicare university clinic charges patients a nominal fee per semester or per year, would evaluation and treatment sessions be recognized as free under Medicare rules?

No.

Is a clinic serving Medicare patients required to bill electronically?

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

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