Wiki Does a facility that doesn't accept Medicare & provides no covered services have to bill Medicare & receive denial before billing a patient?

[esmoot]

Does a facility that doesn't accept Medicare & provides no covered services have to bill Medicare & receive denial before billing a patient? HELP!

 

[thomas7331]

What kind of facility and what services are being provided?

 

[esmoot]

Substance Use Disorder Residential and Outpatient Treatment. Outpatient counselors do not meet Medicare's licensing requirements.

 

[thomas7331]

I think you may want to run this question by an attorney. If the services are not covered simply because they are not a Medicare benefit, then it may be OK to bill the patient for these. But since you're saying they're not covered because of a licensing requirement, that's a different situation. Billing a patient for a service that might be covered if the patient obtained that same service from a different provider could potentially put you in conflict with Medicare laws. Your provider may need to formally opt out of Medicare and have a signed contract with the patient in order to do this. Best to get sound legal advice on this as it is a complex area, and I wouldn't recommend acting based on anonymous answers on a coding forum for something of this magnitude.

 

[ca_cpc]

Slightly different scenario, but if any of patients are dually eligible you may want to check with the secondary. Our state Medicaid has a policy in place that allows us to bypass Medicare and bill them directly for services provided by our non-Medicare counselors, with use of the GY modifier. Our BCBS has a similar policy, I believe as part of the Exchange plans. Obviously that doesn't help with the patients who aren't dually eligible, but it could be worth investigating.