The Facts About Treating Medicare Beneficiaries The rules are clear. If you treat Medicare beneficiaries independently, you must enroll as a Medicare provider. Bottom Line
Free
Bottom Line  |   July 01, 2016
The Facts About Treating Medicare Beneficiaries
Author Notes
  • Tim Nanof, MSW, is director of ASHA health care policy and advocacy. tnanof@asha.org
    Tim Nanof, MSW, is director of ASHA health care policy and advocacy. tnanof@asha.org×
Article Information
Practice Management / Bottom Line
Bottom Line   |   July 01, 2016
The Facts About Treating Medicare Beneficiaries
The ASHA Leader, July 2016, Vol. 21, 28-30. doi:10.1044/leader.BML.21072016.28
The ASHA Leader, July 2016, Vol. 21, 28-30. doi:10.1044/leader.BML.21072016.28
True or false: You can provide services to Medicare beneficiaries in your private practice without becoming a Medicare provider if you bill them privately.
False. Medicare clearly requires audiologists and speech-language pathologists who diagnose or treat Medicare beneficiaries independently to enroll as providers, without the opportunity to “opt out” of the program.
If you answered incorrectly, you are not alone. Many audiologists and SLPs are unclear about Medicare rules for health care professionals who provide services to Medicare beneficiaries.
Here’s the most important thing to know: Medicare recognizes audiologists and SLPs as eligible independent providers. Therefore:
  • Audiologists working independently must enroll to provide services to any Medicare beneficiaries.

  • SLPs in private practice, outpatient clinics and university clinics must enroll to independently provide services to Medicare-eligible patients and clients. (In certain settings, SLPs may bill “incident to” a physician under very limited circumstances that do not apply to most SLPs; see “‘Incident to’ Billing” below.)

How do I enroll in Medicare?
Enrollment is a two-step process that can be completed online. The first step is to obtain a National Provider Identifier (NPI) number. Once you have an NPI, you can submit an enrollment application through the Provider Enrollment Chain & Ownership System (PECOS). All of the information you need is available on the ASHA website—just search “enroll in Medicare.”

Audiologists and SLPs cannot opt out of Medicare. They must comply with all Medicare requirements when treating any Medicare beneficiary.

Physicians can choose not to participate in Medicare. Are audiologists and SLPs also allowed to opt out?
No, audiologists and SLPs may not opt out. Medicare allows very few health care providers (mostly physicians) to do so, and of those, only about 2 percent take the option because they lose a significant referral source and revenue stream.
Opting out is a commonly misunderstood term. It allows a physician to enter into private contracts with Medicare beneficiaries, agreeing that neither physician nor patient will bill Medicare. Concierge physician practices for older adults are based on this option. Audiologists and SLPs—as well as physical therapists, occupational therapists and most other nonphysician providers—cannot opt out of Medicare. They must comply with all Medicare requirements when treating any Medicare beneficiary.
My practice focuses on pediatrics. Do I have to see adults and Medicare beneficiaries?
No, Medicare does not require you to treat beneficiaries. But if you do provide services to any Medicare beneficiary you must be a Medicare provider, you must follow the Medicare rules, you must charge the established Medicare rates, and Medicare must be billed.
I work in a hospital. Do I have to enroll as a Medicare provider?
No, clinicians who provide services in facilities (including hospitals, inpatient rehab facilities, skilled nursing facilities and home health care agencies) are not required to enroll, as their services are billed to Medicare under the facility’s NPI. However, Medicare enrollment allows clinicians more flexibility in choosing how and where to provide services.
My patient doesn’t want me to submit their bill to Medicare. Can I enter into a separate written contract with them?
No, any health care provider who treats Medicare beneficiaries must comply with all Medicare requirements, including enrollment and billing standards.
If the patient prefers, you can provide them with a bill (based on established Medicare rates) and allow them to submit the claim to Medicare. You must collect the 20 percent outpatient co-payment (the Medicare standard) and follow all Medicare rules and regulations. The patient is then free to submit that claim to Medicare at any time. (In this case, you are considered an enrolled, but non-participating, provider.)

If you provide services to any Medicare beneficiary you must be a Medicare provider, you must follow the Medicare rules, you must charge the established Medicare rates, and Medicare must be billed.

If I am not complying with Medicare supervision requirements for clinical fellows and students in my setting—or I am not following other Medicare rules—can I notify patients and charge them a nominal fee under a separate contract?
No, you may not. It is not legal to provide low-cost or free services to Medicare beneficiaries in order to bypass Medicare requirements. If you provide covered audiology and speech-language pathology services to anyone enrolled in Medicare, you must obey the related rules and bill Medicare for the services provided.
The only way to provide free services to Medicare beneficiaries is to provide free services to all of your patients, regardless of payer type. If you decide the best path is to not bill Medicare beneficiaries, then you cannot bill anyone.
I am in private practice as a sole practitioner in my own clinic. Can I bill “incident-to” or do I need to enroll to see Medicare beneficiaries?
If you are not in a physician-run practice or clinic, there is no supervising physician to bill under. In true private practice, enrollment is the only way to provide services to Medicare beneficiaries.
Can I bill Medicare beneficiaries privately if they sign a contract?
No, you may not privately bill Medicare beneficiaries under any circumstances.
Can I bill “incident-to” an enrolled SLP or under their NPI?
No, SLPs may bill incident-to only under physicians (or physician extenders, such as physician assistants). Providers may not allow others to use their NPI.

The only way to provide free services to Medicare beneficiaries is to provide free services to all of your patients, regardless of payer type. If you decide the best path is to not bill Medicare beneficiaries, then you cannot bill anyone.

If I provide an Advance Beneficiary Notice (ABN) notifying the patient that I will not bill Medicare, can I then bill them privately?
No, ABNs are used only to notify a patient that Medicare will likely deny coverage for the services you are providing because they may not meet medical necessity requirements. You are still required to submit the bill to Medicare; the ABN lets the patient know that if Medicare denies the claim, the patient will be responsible for paying you directly.
Can I set my own rates and balance-bill Medicare beneficiaries?
No, you may not charge Medicare patients more than the Medicare-established rate for any service.
So, the only way to independently provide covered services to Medicare beneficiaries and be paid is to enroll as a Medicare provider, follow the rules and bill Medicare?
Yes. Any other actions are illegal and unethical.
These answers may be surprising to some clinicians, who often ask ASHA reimbursement staff when these rules changed. In fact, the rules have not substantively changed (with the exception of private-provider status for SLPs in 2009; gaining independent billing status was a significant achievement).
Audiologists and SLPs have never been allowed to opt out of Medicare or to circumvent any rules or regulations by billing patients privately—with or without written consent.
Medicare enrollment allows audiologists and SLPs to take full advantage of the opportunities and professional obligations offered by Medicare independent provider status and recognizes the valuable services they provide to older adults.
‘Incident-to’ Billing

Some speech-language pathologists have limited opportunities to bill for services through a physician—but do they really want to?

Medicare allows a specific category of SLPs—those working in physicians’ offices and physician-run clinics—to bill their skilled professional services “incident-to” a physician. This option is a carryover from Medicare regulations prior to 2009, when SLPs gained independent billing status under the Medicare Improvements for Patients and Providers Act.

Audiologists are statutorily prohibited from billing incident-to a physician.

The right to enroll as an independent provider is part of Medicare’s full recognition of the importance and value of audiology and speech-language pathology services for older adults and helps protect the professions from challenges to scope of practice.

Enrollment also allows audiologists and SLPs to take full credit for the amount and range of audiology and speech-language services provided to Medicare beneficiaries and to clearly demonstrate their value in the broader health care system. ASHA can use this information to advocate for and defend the coverage and value of these services.

Although providing services incident-to a physician remains an option in physician-run practices, doing so is not advantageous to SLPs for several reasons:

  1. Services and supplies that can be billed incident-to the services of a physician must be:

    • An integral, although incidental, part of the physician’s professional service.

    • Commonly rendered without charge or included in the physician’s bill.

    • Commonly furnished in physicians’ offices or clinics.

    • Furnished by the physician or by auxiliary personnel under the physician’s direct supervision.

  2. Neither audiologists nor SLPs are considered auxiliary personnel.

    Their covered services can be billed directly and independently to Medicare, and they do not require direct supervision when working within their professional scope of practice.

  3. Although incident-to billing remains legal for SLPs,ASHA recommends enrollment.

    Doing so benefits the profession, improves transparency and protects members’ reimbursement by following best practices in billing.

  4. It is in providers’ best interest to enroll and bill independently.

    Medicare announced this year that it is increasing efforts to examine and audit incident-to claims because this category of billing is marked by a disproportionate amount of fraud and abuse.

Medicare Survival Guide

ASHA’s new step-by-step Medicare resource is now available. “The Medicare Survival Guide for Audiologists and Speech-Language Pathologists” guides providers through Medicare processes, policies, laws and regulations. Topics include enrollment, laws and regulations for each type of facility, successful Part A and Part B billing strategies, documentation, supervision requirements and more.

Strategic Health Solutions to Conduct Medicare Manual Medical Reviews

Medicare Part B providers who have a high percentage of patients receiving rehabilitation services beyond $3,700 threshold may be subject to manual medical review, according to information ASHA recently received from the Centers for Medicare and Medicaid Services (CMS).

Strategic Health Solutions, the contractor conducting reviews, will target providers in skilled nursing facilities, private practice and outpatient centers (but not home health care). The contractor will compare provider data across a setting to determine which providers in that setting have the highest percentage of patients exceeding the threshold. CMS noted that the definition of “high” percentage is up to the reviewer, and that the definition could evolve over time.

The contractor will also look at providers who provide “a lot” of daily minutes or hours of therapy per patient.

Strategic Health Solutions began sending additional documentation request (ADR) letters this spring for claims dating back to July 1, 2015. Each ADR covers 40 claims. Clinicians who receive ADRs should follow all instructions, including providing all medical record information requested. The contractor has 45 days to review the claims and medical records and issue a determination.

More information about the manual medical review process will appear in future issues. For more information, contact reimbursement@asha.org.

4 Comments
September 5, 2016
Lynn Fox
A few questions
I have two questions:
1. Do these rules apply to student clinicians who treat medicare eligible clients in university clinics? Often individuals seen in these clinics are charged privately on a sliding scale and Medicare is not billed.
2. Do the rules mean individuals covered by Medicare cannot contract with private SLPs for services after their Medicare cap is reached? In other words, are all individuals insured through Medicare or Medicare Advantage plans prohibited from obtaining further services once their cap is reached?
September 6, 2016
Carol Polovoy
Answer to Lynne Fox from Carol Polovoy, ASHA Leader managing editor
Tim Nanof, author of the article, has answers to your questions.
1. Yes- all Medicare rules apply to students treating Medicare beneficiaries in university clinics. Clinics must comply with the services provision rules--such as 100% direct personal supervision of unlicensed students--and must bill beneficiaries under the fee schedule. Reduced rates based upon financial status of the patient are possible if they are established on a sliding fee scale that is applied to all patients, but the other rules of enrollment and supervision still apply.

2. Audiologists and speech-language pathologists cannot enter into any private-pay contracts for any Medicare-covered services. Services above the cap, when in place, and audiology treatment services are statutorily excluded, so private contracts are allowed if Medicare does not cover a specific service. *The current therapy cap exceptions process is in place through Dec. 31, 2017, so Medicare beneficiaries cannot reach the cap under current law. While the exceptions process is in place, beneficiaries have a right to Medicare-covered services beyond the therapy cap and SLPs cannot enter into private contracts with beneficiaries because it is not possible for them to exhaust their benefit.* The short answer is that SLPs cannot enter into private contracts for skilled therapy services with Medicare beneficiaries in 2016-2017.
September 15, 2016
Michael Towey
Payment Medicare non covered service
Can an SLP bill a Medicare patient and/or provide the service free if the service is a non covered Medicare service; Example: Speech Telepractice/Telerehabilitaion is not a covered service by Medicare, could a patient receive speech by telepractice and pay privately for this non covered service (that would otherwise be covered by Medicare in a clinic setting).
September 19, 2016
Carol Polovoy
Answer to Michael Towey from Sarah Warren,ASHA director of health care regulatory advocacy
If a service is considered covered under Medicare, failing to meet the conditions of coverage do not mean you can charge a Medicare patient for these services directly. Instead, Medicare would expect you to meet the conditions for coverage and submit a claim to the program for these services. For example, under current Medicare legislation, audiologists and speech-language pathologists are not considered eligible providers of services delivered via telepractice. This means that audiologists and SLPs cannot provide their services via telepractice to Medicare beneficiaries. Some providers may believe that because they are not eligible providers of services delivered via telepractice, that they can enter in to private-pay agreements with beneficiaries, or, provide an Advance Beneficiary Notice (ABN) to the beneficiary, since Medicare would not reimburse for those services. However, because audiology and speech-language pathology services are covered services under the Medicare benefit, the services must be provided to Medicare beneficiaries within the confines of Medicare rules.

If you have questions regarding Medicare, including enrollment, please contact Sarah Warren, MA, director, health care regulatory advocacy at swarren@asha.org. For questions related to telepractice, please contact Kate Ogden, MPH, health policy associate, at kodgne@asha.org.
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
July 2016
Volume 21, Issue 7