Wiki LPC + Medicare Questions

b3ckalano

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Hello there!

I am a relatively new biller and feel completely out of my depth trying to navigate Medicare, and can't get info from them directly either. I was hoping there may be someone who has handled this scenario before:

I work for an LPC who never enrolled with Medicare (PAR/nonPAR/Opt-out) because from her understanding, LPCs can't enroll. Now, she has a patient who has Medicare, Commercial insurance, and then Medicaid. We can't get the secondary/commercial insurance to pay because we can't get a Medicare EOB, and we can't get the tertiary/Medicaid to pay because we can't get an EOB from the secondary/commercial insurer.

-From what I've found, LPCs can enroll in Medicare, but they won't pay for their services. Correct?
-Can we even enroll as PAR? If they won't pay out, might as well enroll as non-PAR or Opt-out, right?
-If we go Opt-out, does the patient need to sign the Opt-out waiver still (even if we know Medicare won't pay out for LPC services, anyway)?
-If we enroll and are able to send in a claim to Medicare, but they don't pay because they don't cover LPC services - doesn't that mean the secondary/commercial insurance won't have to pay, either? (Generally, I understand some payers may have exceptions)

It's so complex it feels like there's an elephant in the room but I can't see it - so if I am missing a huge piece of the puzzle please let me know.

THANK YOU THANK YOU THANK YOU!
 
Hello there!

I am a relatively new biller and feel completely out of my depth trying to navigate Medicare, and can't get info from them directly either. I was hoping there may be someone who has handled this scenario before:

I work for an LPC who never enrolled with Medicare (PAR/nonPAR/Opt-out) because from her understanding, LPCs can't enroll. Now, she has a patient who has Medicare, Commercial insurance, and then Medicaid. We can't get the secondary/commercial insurance to pay because we can't get a Medicare EOB, and we can't get the tertiary/Medicaid to pay because we can't get an EOB from the secondary/commercial insurer.

-From what I've found, LPCs can enroll in Medicare, but they won't pay for their services. Correct?
-Can we even enroll as PAR? If they won't pay out, might as well enroll as non-PAR or Opt-out, right?
-If we go Opt-out, does the patient need to sign the Opt-out waiver still (even if we know Medicare won't pay out for LPC services, anyway)?
-If we enroll and are able to send in a claim to Medicare, but they don't pay because they don't cover LPC services - doesn't that mean the secondary/commercial insurance won't have to pay, either? (Generally, I understand some payers may have exceptions)

It's so complex it feels like there's an elephant in the room but I can't see it - so if I am missing a huge piece of the puzzle please let me know.

THANK YOU THANK YOU THANK YOU!


This link has the information on becoming a Medicare provider or supplier, and it includes the opt-out information as well: Become a Medicare Provider or Supplier | CMS

Everything on that link indicates that you have to be an eligible provider type to submit an application. To me, that means that an LPC is not eligible to become par or to opt-out. The link also says that you should contact your local MAC (Medicare Administrative Contractor) with any questions about the application process.

I'd suggest contacting your MAC if you want a definitive answer from an official source.
 
This link has the information on becoming a Medicare provider or supplier, and it includes the opt-out information as well: Become a Medicare Provider or Supplier | CMS

Everything on that link indicates that you have to be an eligible provider type to submit an application. To me, that means that an LPC is not eligible to become par or to opt-out. The link also says that you should contact your local MAC (Medicare Administrative Contractor) with any questions about the application process.

I'd suggest contacting your MAC if you want a definitive answer from an official source.
Thank you!

Unfortunately, I can't get any questions answered from my MAC because the phone line requires an NPI and my LPC's NPI isn't recognized by Medicare. I have done some digging on the CMS site but can't get definitive answers. I will keep looking, but the advice is greatly appreciated!
 
Thank you!

Unfortunately, I can't get any questions answered from my MAC because the phone line requires an NPI and my LPC's NPI isn't recognized by Medicare. I have done some digging on the CMS site but can't get definitive answers. I will keep looking, but the advice is greatly appreciated!

You could email the MAC's customer service instead of calling. In fact, I'd suggest doing that so that you have a written response documented.

FWIW, I think that the CMS website is actually is providing a definitive answer that your provider is not eligible to register with Medicare. The language in every step of the process states that you must be an eligible provider type even to opt-out of Medicare.

However, if your provider wants something more crystal clear in writing, you could email the MAC and get that for her.
 
I'm guessing your MAC is Noridian, since your profile says Oregon. Noridian has a Contact Us form that providers can use to get questions answered about Medicare regulations and coverage:

 
LPCs are not able to be reimbursed by Medicare, they are statutorily excluded. Is this clients secondary a medicare supplement or a commercial insurance? Medicare does not accept claims for "denial purposes only". If the secondary is a Medicare supplement they only pay if Medicare does. If the secondary is a commercial explaining to them that their license is excluded from medicare can be an uphill battle. Some secondary plans will only pay 20% even without reimbursement from medicare. Is the LPC in practice alone? They can bill incident to if they are under someone that isn't excluded from Medicare. I would contact the secondary if it is a commercial plan and not a supplement to see what they suggest or a provider rep if you are in network with them. Some LPC's don't see Medicare patients for that exact reason.
 
Hello there!

I am a relatively new biller and feel completely out of my depth trying to navigate Medicare, and can't get info from them directly either. I was hoping there may be someone who has handled this scenario before:

I work for an LPC who never enrolled with Medicare (PAR/nonPAR/Opt-out) because from her understanding, LPCs can't enroll. Now, she has a patient who has Medicare, Commercial insurance, and then Medicaid. We can't get the secondary/commercial insurance to pay because we can't get a Medicare EOB, and we can't get the tertiary/Medicaid to pay because we can't get an EOB from the secondary/commercial insurer.

-From what I've found, LPCs can enroll in Medicare, but they won't pay for their services. Correct?
-Can we even enroll as PAR? If they won't pay out, might as well enroll as non-PAR or Opt-out, right?
-If we go Opt-out, does the patient need to sign the Opt-out waiver still (even if we know Medicare won't pay out for LPC services, anyway)?
-If we enroll and are able to send in a claim to Medicare, but they don't pay because they don't cover LPC services - doesn't that mean the secondary/commercial insurance won't have to pay, either? (Generally, I understand some payers may have exceptions)

It's so complex it feels like there's an elephant in the room but I can't see it - so if I am missing a huge piece of the puzzle please let me know.

THANK YOU THANK YOU THANK YOU!
I recommend reaching out to a professional association for LPCs, such as the American Counseling Association. They may even have some information on their website that will help.
 
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