Generally speaking, it’s not always clear whether or not you can actually bill your patients for any services that are deemed “non-covered” by Medicare – you normally have to have a pretty thorough understanding of the program’s various rules and regulations to be any closer to knowing.

So, throughout this article, we’ll be exploring the general concept of Medicare non-covered services and when it’s actually permissible to bill a patient for them.

Aside from this, we’ll also be taking a look at the importance of following local and national coverage determinations, so continue reading to be brought up to speed.

Understanding Non-Covered Services

As it currently stands in America, Medicare is a federal health insurance program that primarily focuses on providing older individuals, usually aged 65 and older, coverage for any healthcare treatments they might need. It’s worth quickly mentioning that they cater to certain younger individuals with disabilities, too.

Still, while Medicare is incredibly useful for the average American, especially given how devastating private healthcare costs can be, not every kind of medical service is actually covered by this program. Fairly aptly named, any of the services that fall outside of Medicare coverage are referred to as “non-covered services.”

Obviously, this is a pretty broad term, but the majority of non-covered services tend to include things like cosmetic surgery, hearing aids, or any other kinds of service that Medicare classifies as not medically reasonable and necessary.

As for you, the physicians, the distinction between covered and non-covered services is something that you’ll want to get your head around, given that it determines whether Medicare is actually going to pay for the service in question or not.

The Role of Local and National Coverage Determinations

So, to determine whether any given service is covered or non-covered, Medicare uses two main documents: local coverage determinations (LCDs) and national coverage determinations (NCDs).

Though these documents sound like quite intimidating jargon, they’re actually fairly simple – LCDs are for coverage within specific parts of the country, whereas NCDs are issued directly by the Centers for Medicare & Medicaid Services (CMS) and apply all across the country.

In essence, it’s your job to consult these determinations so you have a clear idea of whether a particular service is actually reimbursable under Medicare.

Aside from generally ensuring you’re being paid properly, it can lead to pretty serious billing errors and even liability issues if you ignore these documents, so it’s imperative that you’re aware of the ins and outs.

Furthermore, it’s worth noting that these determinations are regularly updated, too, so you’ve got to be aware of any changes when it comes to remaining compliant.

When Can You Bill a Medicare Patient for Non-Covered Services?

Let’s walk through some of the most common scenarios where this may be permissible:

1. Services Authorized by the Patient

If a Medicare patient wishes to receive a non-covered service and is fully aware that Medicare isn’t going to cover it, you’re naturally able to bill the patient directly here – just make sure you have their consent and clearly communicate all the costs involved.

2. Cosmetic Surgery

Cosmetic surgery is a great example of a non-covered service under Medicare as you’re generally always able to directly bill the patient if they’re looking for an elective cosmetic surgery like a rhinoplasty, for instance.

3. Whether or Not They Support Medical Necessity

Similar to the previous example, Medicare tends to classify any services that aren’t considered medically reasonable or necessary for a patient’s condition as not a covered service, meaning you can bill them directly for it.

4. Services Reimbursable Under Liability Insurance

If one of your patient’s medical conditions is caused by an accident or some other kind of injury but is covered by liability insurance, you’re usually able to bill the liable party’s insurance company directly for the services rendered or any medical devices you use.

Still, you’ve got to comply with Medicare’s coordination of benefits rules to remain fully compliant.

5. Certain Services Outside The Medicare Benefit Structure

Any other services like physician standby services, custodial care, or even skilled nursing facility care might not fall under Medicare’s coverage, so in these cases, you should be able to bill the patient for these.

Maintaining Compliance With PMN

As touched on, there are pretty serious consequences for not knowing whether or not you can actually bill a Medicare patient for the services you’ve performed – the least of your concerns being that you aren’t properly reimbursed.

So, to ensure you’re always staying compliant with the relevant and ever-changing coverage determinations, it’s worth collaborating with a third-party medical billing and coding company such as PMN.

When it comes to actually billing your patients, PMN can greatly reduce the number of claim denials you receive thanks to their eclectic team of billing specialists – not to mention helping you reduce your A/R days and providing monthly reports for you, too.

If you’d like to hear more about the kinds of services PMN offers, get in touch today by calling (949) 215-5055 or visiting our office in Laguna Hills, Orange County, California!

FAQs

What Happens If I Incorrectly Bill a Medicare Patient For a Non-Covered Service?

Aside from having a very unhappy patient, incorrectly billing for any non-covered services tends to result in payment disputes and even potential legal issues. So, to avoid this, it’s vital to follow Medicare rules, obtain patient consent whenever you can, and generally try to ensure accurate documentation in case of any errors.

Can I Bill a Medicare Patient For Services That Were Denied By Medicare?

Generally speaking, this is not advisable due to the fact that if Medicare denies a service, it typically means they consider it non-covered, which can complicate things if you try to bill the patient. In these cases, you’re typically better off appealing Medicare’s decision rather than billing the patient directly.