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Non covered service

  1. #1
    Location
    Evansville Indiana
    Posts
    451
    Default Non covered service
    Medical Coding Books
    If a provider performs a service that is considered experimental/non-covered by Medicare, are they required to offer it to Medicare patients (with ABN) if they offer it to commercial patients, or can they limit the service to commercial patients only? Citations would be appreciated>

    Thanks
    LeeAnn

  2. Default
    A provider would only offer a service to a patient if considered medically necessary and appropriate for the patient's diagnosis or condition. He/She should only offer the service (experimental or not) to those patients in which he would feel that this would medically benefit them. I cant really see a situation in which he would think one procedure would be beneficial for every single patient. If he is only offering this service to commerical patients and not patients with other payors, I would be a little wary about this. You shouldn't only offer a service to a patient because their insurance may pay and or you can bill the patient if their insurance denies as experimental.

  3. #3
    Location
    Tacoma, WA
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    1,087
    Default
    Quote Originally Posted by cheermom68 View Post
    If a provider performs a service that is considered experimental/non-covered by Medicare, are they required to offer it to Medicare patients (with ABN) if they offer it to commercial patients, or can they limit the service to commercial patients only? Citations would be appreciated>

    Thanks
    LeeAnn
    If it truly considered experimental, or otherwise always non-covered by Medicare, an ABN is not required. I don't believe there is anything on the Medicare website that states the provider MUST offer the same experimental or non-covered services to Medicare patients as they do to commercial patients. Is this a service that IS covered by some commercial insurances?
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  4. #4
    Location
    Evansville Indiana
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    451
    Default non covered
    this is what I found in the Medicare Claims processing Manual. It seems to suggest that If you have two patients with the same condition requiring a certain treatment, you cannot offer only to commercial patients and not Medicare.


    Medicare Claims Processing Manual
    Chptr 1 30.1.3 Provider Treatment of Beneficiaries In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment. The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment. If the provider does not furnish treatment for certain illnesses and conditions to patients who are not Medicare beneficiaries, it need not furnish such treatment to Medicare beneficiaries in order to participate in the Medicare program. It may not, however, refuse to furnish treatment for certain illnesses or conditions to Medicare beneficiaries if it furnishes such treatment to others. Failure to abide by this rule is a cause for termination of the provider's agreement to participate in the Medicare program.

  5. #5
    Location
    North Carolina
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    3,126
    Default
    Quote Originally Posted by cheermom68 View Post
    this is what I found in the Medicare Claims processing Manual. It seems to suggest that If you have two patients with the same condition requiring a certain treatment, you cannot offer only to commercial patients and not Medicare.


    Medicare Claims Processing Manual
    Chptr 1 30.1.3 Provider Treatment of Beneficiaries In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment. The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment. If the provider does not furnish treatment for certain illnesses and conditions to patients who are not Medicare beneficiaries, it need not furnish such treatment to Medicare beneficiaries in order to participate in the Medicare program. It may not, however, refuse to furnish treatment for certain illnesses or conditions to Medicare beneficiaries if it furnishes such treatment to others. Failure to abide by this rule is a cause for termination of the provider's agreement to participate in the Medicare program.
    Agree...

  6. #6
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by cheermom68 View Post
    this is what I found in the Medicare Claims processing Manual. It seems to suggest that If you have two patients with the same condition requiring a certain treatment, you cannot offer only to commercial patients and not Medicare.


    Medicare Claims Processing Manual
    Chptr 1 30.1.3 Provider Treatment of Beneficiaries In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment. The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment. If the provider does not furnish treatment for certain illnesses and conditions to patients who are not Medicare beneficiaries, it need not furnish such treatment to Medicare beneficiaries in order to participate in the Medicare program. It may not, however, refuse to furnish treatment for certain illnesses or conditions to Medicare beneficiaries if it furnishes such treatment to others. Failure to abide by this rule is a cause for termination of the provider's agreement to participate in the Medicare program.
    But this is intended for services that would be covered under the Medicare program. I do not think the same rule applies if the treatment is considered experimental and is never covered by Medicare. That medical service becomes exempt from this requirement, just as it is exempt from the ABN requirement. The physician can still certainly present the treatment to the patient, but also stating it will not be covered by their Medicare plan, so the patient will be responsible for payment in full.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  7. #7
    Default
    That is excellent information and I agree as this is what we did in Dermatology also.

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