Although the above categories describe services that are generally not covered, exceptions to each category exist that would permit and/or require payment by Medicare or a commercial payer, as applicable. Therefore, it’s recommended that when dealing with a non-covered service, you review the applicable exceptions to determine if the service could actually be covered under an exception to the non-coverage category.
Explore this issue:May 2017
When dealing with a non-covered service … review the applicable exceptions to determine if the service could actually be covered.
Medicare and Advanced Beneficiary Notices
You must give written notice to a fee-for-service patient prior to rendering services that are usually covered by Medicare, but are not expected to be paid in a specific instance. This notice is known as an Advanced Beneficiary Notice of Noncoverage (ABN).
The ABN allows a patient to make an informed decision about whether to receive the service and accept financial responsibility if Medicare does not pay. It also allows the patient to better participate in treatment decisions by making informed decisions. The ABN must list the items or services that Medicare is not expected to pay and the reasons why Medicare may not pay, and include an estimate of costs for the items or services.
If the patient does not receive an ABN when it is required, he or she may not be held financially liable if Medicare denies payment. If the patient is provided an ABN and notified that the service may not be covered, and the patient agrees to pay out of pocket, you may bill the patient for the services. The patient must be provided with a copy of the fully executed ABN and a copy must also be retained in the patient’s medical record.
It is worth noting that you are not required to notify a patient before providing a service that Medicare never covers (i.e., the non-covered services discussed above) or that is not a Medicare benefit. In such instances, however, you may voluntarily provide the patient with an ABN or other written informed notice of non-coverage as a courtesy to alert the patient that he or she will be financially liable for the services. When ABNs are issued on such a voluntary basis, the patient is not required to sign the notice, there is no impact on the patient’s requirement to pay for the services, and you may still bill the patient.
Upon receipt of an ABN, patients always have the right to ask you to submit a claim to Medicare for an official payment decision. However, in order to request a Medicare claim submission, the patient must actually receive the service described in the ABN.
Often, you will be permitted to seek and collect payment from patients for services not covered under the patient’s commercial (i.e., non-government payer) insurance plan if you obtain the patient’s prior written consent to receive such services. Typically, the consent must be signed and dated by the patient prior to rendering the services in question. It should state that the services will not be covered by the patient’s insurance plan and that if the patient chooses to receive the services, he or she will be financially responsible for their cost.