Eli's Rehab Report

Published on Mon Nov 24, 2008 PDF

Question: We're a private speech-language practice that's shifted its focus to pediatrics, so we've decided to no longer participate in the Medicare program. Does this mean we're free from dealing with payer red tape and lengthy claims processes?

-- Washington Subscriber

Answer: You'll definitely have some relief, but you're not completely off the hook. For one, your SLPs may eventually treat a Medicare beneficiary. Remember, Medicare covers some disabled people under age 65, as well as people of all ages with End-Stage Renal Disease.

The good news: CMS recently issued Transmittal 1557 (www.cms.hhs.gov/transmittals/downloads/R1557CP/pdf), which indicates that under certain circumstances, carriers will process claims that beneficiaries self-submit to Medicare.

The bad news: The new transmittal doesn't change the fact that non-par providers must submit claims to the carrier on the patient's behalf, (and that those who have opted out cannot bill Medicare). The transmittal notes that it will keep track of each "provider or supplier that refuses to submit a claim on the beneficiary's behalf," and that it will keep a list of the "top 50 violators, by state, of the mandatory claim submission policy."

Non-participating providers must file claims to Medicare, and they'll collect the limiting charge. On the other hand, if you have opted out of the Medicare program, you privately contract with Medicare patients and you do not have to submit claims to Part B for their care.

Here's how: A provider that has opted out of Medicare may agree to treat a Medicare patient on a non-emergent basis, on the condition that the patient will not file the claim to Medicare. If the practice opts out of Medicare, it can enter into a written contract, signed by the patient, stating that the provider will not file the claim with Medicare and the patient won't do so, either.