Medicare: A Must When Treating Older Patients Medicare patients cannot pay out-of-pocket for covered audiology and speech-language pathology services. In Private Practice
Free
In Private Practice  |   December 01, 2018
Medicare: A Must When Treating Older Patients
Author Notes
  • Sarah Warren, MA, is director of ASHA Medicare policy. swarren@asha.org
    Sarah Warren, MA, is director of ASHA Medicare policy. swarren@asha.org×
  • Tim Nanof, MSW, is director of ASHA health care and education policy. tnanof@asha.org
    Tim Nanof, MSW, is director of ASHA health care and education policy. tnanof@asha.org×
Article Information
Speech, Voice & Prosodic Disorders / Hearing Disorders / Audiologic / Aural Rehabilitation / Special Populations / Older Adults & Aging / Practice Management / In Private Practice
In Private Practice   |   December 01, 2018
Medicare: A Must When Treating Older Patients
The ASHA Leader, December 2018, Vol. 23, 40-41. doi:10.1044/leader.IPP.23122018.40
The ASHA Leader, December 2018, Vol. 23, 40-41. doi:10.1044/leader.IPP.23122018.40
Some audiologists and speech-language pathologists setting up private practices may plan to let their patients deal with insurance. Why not collect fees from patients, they think, and then give patients a bill to send to their own insurance companies?
That system can work for some patients—children and adults younger than 65—but not for Medicare-eligible patients. Taking direct payment for covered services from Medicare patients (people 65 and older who don’t have other insurance or people of any age who qualify by virtue of a disability) can actually violate federal law.
What’s the law?
The federal Social Security Act requires audiologists and SLPs to enroll in and bill Medicare when they provide any covered services to a Medicare beneficiary. Therefore, a provider who accepts money from a beneficiary for services that Medicare covers is violating the law.
Medicare is a federal benefit program that is assigned to the beneficiary. Because the policy follows the beneficiary, the beneficiary may only receive care from audiologists and SLPs who are enrolled in the Medicare program.
Specifically, all workers pay into the Medicare trust fund through the course of their working lives. When they qualify for Medicare, the program funds their health care.

A provider who accepts money from a beneficiary for services that Medicare covers is violating the law.

Why can’t patients just pay me directly if they want to?
Medicare enrollment and claims submission process are confusing to providers and beneficiaries. But trying to circumvent them for covered services violates federal law.
Mandatory enrollment and claims submission are designed to protect beneficiaries. Medicare rules ensure fixed rates, prohibit balance-billing (billing patients for the difference between Medicare reimbursement and the provider’s fee), and set standards to ensure quality of providers.
Other professionals can opt out of Medicare. Why can’t we?
Medicare allows a select list of clinicians to opt out and bill patients directly. The list, codified in federal law, mostly includes different types of physician specialties. Although physicians may receive payment directly from Medicare beneficiaries and establish “boutique” practices, most providers cannot.
Audiologists, SLPs, occupational and physical therapists, nurses, and many others cannot opt out. Adding any of these professionals to the opt-out list would require a change in federal law, and no profession has been added since 1985. Interestingly, only about 1 percent of physicians eligible to opt out actually do so.
I accept payment from Medicare beneficiaries, and nothing has ever happened.
Audiologists and SLPs accepting direct payment from Medicare beneficiaries for covered services are violating the law and may be unaware of the requirements and consequences. As part of the effort to decrease Medicare spending, provider scrutiny is on the upswing and federal officials have stepped up enforcement efforts.
If the Medicare Inspector General or the Department of Justice identifies providers who are accepting payment from Medicare beneficiaries for covered services, the providers may face prosecution under the False Claims Act, with penalties of triple damages (three times the amount that should have been billed) plus an additional $2,000 per claim. These penalties add up quickly with multiple claims per patient.

Providers who treat Medicare beneficiaries have only one option: to comply with Medicare policy. For private practitioners and outpatient clinic employees, compliance means you likely need to enroll.

How do I know if a service is covered by Medicare?
The only audiologic Medicare-covered service is diagnostic testing with a physician order. Medicare does not cover audiology treatment and hearing aids, so audiologists may bill the patient for these services.
Speech-language pathology coverage depends on:
  • Medical necessity—if the services treat an illness, injury or functional impairment.

  • Skilled care—if the services require the skills and training of an SLP.

If a service is medically necessary and skilled, it is covered and Medicare rules apply. Most speech-language services for a functional impairment are covered in principle with no categorical medical necessity exclusions. Patients cannot be denied care even if, for example, they have been discharged from skilled care, reached a certain goal, or had the condition for a long time. Clinicians must individually assess a patient to determine medical necessity for skilled care.
Two recent events underscore patients’ ability to receive services for long-standing conditions. Congressional repeal of the therapy cap eliminated limits on how much therapy Medicare covers for a patient in a year. The “Jimmo” decision requires Medicare to cover treatment that maintains function or prevents deterioration of function. As a result, the overwhelming majority of the speech-language services are covered and previous exclusions no longer apply.
Medicare rules apply to all covered services. The clinician is responsible for determining medical necessity and for the consequences of an incorrect determination.
What options do providers have?
Providers who treat Medicare beneficiaries have only one option: to comply with Medicare policy. For private practitioners and outpatient clinic employees, compliance means you likely need to enroll. If you do not want to enroll in Medicare, you cannot treat Medicare beneficiaries at all.
ASHA provides detailed information on enrolling in Medicare for audiologists and SLPs.
Enrolling in Medicare may not be necessary if most of your clients are children. But not enrolling can be extremely limiting if you primarily serve adult clients. If you choose not to enroll in Medicare, you should refer beneficiaries to an enrolled provider.
SLPs (but not audiologists) who work with physicians could consider billing “incident to” a physician. In this scenario, the physician must be affiliated with the specific practice and provide direct supervision (defined by the physician’s presence in the office) of the SLP. This option can be limiting, costly and administratively burdensome.
What about Medicaid and private health plans?
Federal requirements for enrollment and claims submission apply only to Medicare. Each state’s Medicaid agency sets its own policy about accepting direct payment from Medicaid beneficiaries, and those policies vary significantly. Check with your state’s Medicaid agency to identify applicable rules.
Similarly, private health plans have different processes and standards for treating beneficiaries in or out of network. It’s advisable to have a working knowledge of payment policies for health plans in your area.
0 Comments
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
December 2018
Volume 23, Issue 12