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Excluded Services Certain services are not covered under Medicare. Also, if a psychologist performs a service that is not within the scope of his/her license or state law, the service would be disallowed.
Carrier Screens Screens are not limits or ceilings on services. Screens are parameters HCFA or the carrier uses to determine reasonable levels of care. Screens are used to suspend a claim for review. Carriers are expected to manually review services that exceed screens, but in actual practice, the amount of additional review may be minimal. Many services that exceed screens do seem to be rejected initially. The most common screens (and the ones that have the greatest impact on psychologists) are based on frequency. These screens allow automatic payment for a set amount of services over a period of time for specific diagnoses. For example, so many hours of testing are allowed, as are so many therapy sessions or hours of therapy a month before Medicare questions the service.
Policy for Psychological Services
Medical Necessity Medicare determination of what services are "reasonable and necessary" will not always match the providers' or the beneficiaries' view of needed services. However, claims denials or claims reductions based on the "reasonable and necessary" requirement are always open to appeal. Occasionally, psychologists will find that a claim is denied although the service is clearly a reasonable and necessary covered service. In this case, there may be an error in the HCFA 1500 claim form. These forms must be filled out completely, carefully, and legibly. Since Congress and the Administration do not want Medicare beneficiaries to suffer excessive out-of-pocket expense, providers are normally financially liable for services that are deemed not "reasonable or necessary." HCFA's requirements for determining liability13 are quite strict with regards to whether or not a provider could reasonably have been expected to know that Medicare would pay for the service. One sentence in an old newsletter or a previous denial for the same service usually suffices as proof that the provider could reasonably be expected to know that the service would not be paid for by Medicare. HCFA states that the psychologist is not financially liable if he/she did not know and could not have been reasonably expected to know that Medicare would not pay for the service. For example, in the absence of any previous notification, having a billing history that clearly demonstrates correct coverage assessments by the provider would show that the provider was not likely to know that the service would not be covered. In these cases, psychologists may collect payment from beneficiaries for services that are considered by Medicare to be not "reasonable and necessary." However, in situations in which services furnished do not meet locally acceptable standards of practice, the provider is considered to have known that Medicare payment for the service would be denied.
Advance Beneficiary Notice Instructions regarding adequate written notice to beneficiaries are very stringent. A form letter to all beneficiaries for all services is unacceptable. A general statement that Medicare denial is possible or that payment by Medicare is uncertain would also be unacceptable. Notices should only be given when there is genuine doubt regarding Medicare's payment for a particular service. According to HCFA instructions, the advance notice to the beneficiary must "clearly identify the particular service, must state that the physician [or psychologist] believes Medicare is likely to deny payment for the particular service and must give the physician's [or psychologist's] reason(s) for his/her belief that Medicare is likely to deny payment for the service."14 HCFA's sample notice15 follows: Psychologist notice to beneficiaries: "Medicare will only pay for services that it determines to be 'reasonable and necessary' under section 1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is 'not reasonable and necessary' under Medicare program standards, Medicare will deny payment for that service. I believe that, in your case, Medicare is likely to deny payment for (specify particular service(s)) for the following reasons: (the psychologist indicates the specific reason(s) for his or her belief that the service(s) would not be covered)_________________ Beneficiary Agreement:
I have been notified by my psychologist that he/she believes that, in my case, Medicare is likely to deny payment for the services identified above, for the reasons stated. If Medicare denies payment, I agree to be personally and fully responsible for payment.
Signed,
Acceptable reasons to list in the notice to beneficiaries include16:
The above notice and agreement must be attached to the HCFA 1500 claim form when the claim is initially submitted. Carriers have been advised by HCFA not to reject a claim simply because the waiver is attached. Along with the advance beneficiary notice, a cover letter to beneficiaries explaining why they are being asked to sign a form might be useful. Such a letter might explain that Medicare and providers do not always agree on what constitutes quality care, possibly because expenditure reduction is a priority for the federal government while quality of care is your top priority. It is also useful to explain that by signing the statement, the beneficiary understands that they agree with your professional judgment, wants the additional services and is willing to pay for those services in the event that such services are deemed not "reasonable and necessary." Medicare does not hold the beneficiaries financially accountable for the professional judgment of their providers, therefore the providers are financially responsible for the reasonableness and necessity of the services they provide. Services that are denied because they are not deemed "reasonable and necessary" are often covered services, but are denied or reduced because they have exceeded some boundaries, i.e., individual therapy is a covered service but individual therapy four times a week would probably be considered not "reasonable and necessary". Psychologists who provide psychological testing may find that their claims are reduced rather than denied outright. Carriers reduce the number of hours in the claim and pay a lesser amount. This reduction is usually based on whether or not the carrier deems the additional hours to be reasonable and necessary. There are certain situations where Medicare coverage of particular services is less definitive resulting in questions regarding what a provider can charge the beneficiary for such services. If existing policy specifically states that the service is not a covered Medicare service, like psychophysiological therapy (psychotherapy incorporating biofeedback training - CPT codes 90875 and 90876), then there is no limiting charge (see glossary) and the provider can charge whatever she/he wants. Similarly, in situations where services are sometimes covered but, due to specific Medicare coverage restrictions, the particular service rendered might not meet these coverage requirements, then there are no limiting charges, and the provider can again charge what they like (see section on family psychotherapy as an example). However, coverage in this case is based on carrier discretion and thus the provider cannot be certain whether the service will be paid until the carrier makes its coverage determination. If the provider chooses to collect more than the Medicare approved amount (see glossary) from the beneficiary and Medicare pays the claim, then any monies collected above what Medicare approves would have to be repaid to the beneficiary. In this situation, an ABN is an "enlightened and prudent practice," though not a requirement. The ABN should be designed to clearly indicate the intent of the provider and thus may protect the provider if a claim is questioned by either the carrier or the beneficiary. The ABN basically states, in advance, why the provider does not think Medicare will cover the service (see sample under section entitled "Advance Beneficiary Notice"). There are some situations where a service would be covered by Medicare, however the beneficiary, for reasons of his or her own, declines to authorize the psychologist to submit a claim or to furnish confidential medical information to Medicare that is needed to submit a proper claim. Examples would be where the beneficiary does not want information about mental illness or HIV/AIDS to be disclosed to anyone. This arrangement does not require a private contract, however the psychologist may not charge more than the limiting amount (115% of what Medicare allows). The psychologist should have this request in writing and in the beneficiary's file. Moreover, the beneficiary can choose to have the claim submitted at a later date, at which point, if the service is paid by Medicare, the psychologist must pay back monies collected beyond what Medicare allows. In the case of a service not being covered due to reasons of "medical necessity" (typically frequency of services fits here), then the provider is not subject to Medicare's approved amount as long as they have given the beneficiary an ABN. This is the only scenario where an ABN is required. Otherwise, if Medicare does not cover the service and no ABN was given, it is likely the psychologist will not get paid by Medicare for the service. Furthermore, because the beneficiary was not expected to know it would not be covered, and the provider should have known it would not be covered, the provider cannot collect any payment from the beneficiary for the service.
Evaluation and Management Services It is HCFA's policy that E&M services can only be provided by and paid to physicians. At present, psychologists are not defined as "physicians" for Medicare coverage, therefore HCFA will not pay for any E&M services provided by psychologists, even if provided under an "incident to" arrangement with a physician (see "incident to" section)17.
Diagnostic Screenings
Experimental Treatments
Services with Coverage Restriction Guidelines FAMILY PSYCHOTHERAPY - Similarly, family psychotherapy has some coverage restrictions. Medicare will only cover family counseling services where the primary purpose of the service is, "the treatment of the patient's condition." Specifically, Medicare identifies the following two situations where family counseling would be covered: "1) where there is a need to observe the patient's interaction with family members; and/or 2) where there is a need to assess the capability of and assist the family members in aiding in the management of the patient."19 Medicare will not cover counseling that is principally concerned with the effects of the patient's condition on the family member being interviewed. This type of counseling is not considered part of the psychologist's personal service to the patient. |
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