For example, Medicare sends the practice an EOB (explanation of benefits) denying the non-covered charge as well as one to the patient stating that the physician may not bill the patient for these charges. (The Omnibus Budget Reconciliation Act of 1988 limits the amount Medicare patients are liable for services and procedures that are denied as not reasonable and necessary.)
Without a waiver of liability on file, youve just lost your right to collect for those charges, says Sheila Sylvan, principal of IMPACT Medical Consulting in Atlanta, GA. You must have this statement signed in advance of the procedure or service or you cant bill the patient for the non-covered services, she adds.
Because a high percentage of cardiology patients are Medicare beneficiaries, writing off even occasional denials will eventually add up. In addition, auditors may ask to see waiver statements in a prepayment audit.
Here are six tips to help you stop revenue leaks and remain in compliance with Medicare Law (see sample form on page 7):
1. Cite the regulation.
Along with your name and address, and the patients name and Medicare number, make sure the statement clearly, yet briefly, outlines the reason for the waiver.
2. Use first person.
Include a paragraph indicating that the patient understands he or she is responsible for full payment.
2. Explain what is likely to be denied.
Use blanks in which the physician can briefly list each service or procedure, the date, the charge, and the reason why Medicare may deny payment. You can list multiple procedures and dates of service on one waiver statement.
3. Notify patient in advance.
Make sure the patient signs the waiver before each service or procedure is rendered. A blanket waiver is not acceptable. Give a copy of the agreement to the patient and keep one in their chart.
The patient must sign in advance of the procedure, indicating that they understand they will be responsible for payment, explains Connie Cofer, CPS, Cardiovascular Group in Lawrenceville, GA. You cant have them sign it after the test, nor can you have them sign a blank or a general statement for future situations.
4. Bill correctly.
Even though Medicare will not reimburse for the procedure or service, you still must bill your carrier for it. Use the modifier GA, which tells Medicare they are to note on the EOB that the patient is responsible for payment.
5. Watch for routine procedures.
For example, unless the patient specifically signs a waiver for a B12 shot, hepatitis test, liver test, nutritionist services, and/or a screening, youll end up absorbing the costs.
6. Keep all staff up-to-date.
Carrier bulletins contain the latest information on what procedures are considered not reasonable and necessary. But instead on distributing various memos or notices, consider keeping a running list at a central location. For example, one Atlanta cardiology practice keeps a booklet at the nurses desk with the instructions, If you are ordering a test for a diagnostic condition other than those listed below, please have the patient sign a waiver.
The covered test booklet described above includes diagnostic codes that support medical necessity for EKG, event monitors, Holter monitors, stress ECHOs, and chest x-rays.
Timesaving tip: Instead of having the physician write out the reason why Medicare is most likely to deny payment for each service or procedure, list all 14 reasons at the bottom of the waiver statement. Then the physician need only select a number from the list and note it (see form below).