In true Medicare doublespeak … The answer is both YES – and NO. But I Don’t Want to Enroll in Medicare!
There are three categories of Medicare provider enrollment. The government expects all Medicare-eligible clinicians to make a choice and enroll accordingly.
What they DON’T want, is for clinicians to refrain from choosing. The government expects all Medicare-eligible clinicians to enroll in Medicare or opt-out. There can be negative consequences to staying outside the system.
Attention: Counselors and Marriage-Family Therapists, beginning in 2024 this will include YOU, as well!
For the uninitiated, Medicare seems designed to frustrate, with all its acronyms, lingo, and peculiarities. But it doesn’t have to be this way.
Participating – There is no “credentialing” in Medicare. Compared to a private insurer, it’s a relatively straightforward and short process. (Keyword here being relatively…!)
To enroll on paper, you file the appropriate forms: CMS 855I (for individuals) 855B (groups) 855R (individual group members reassigning benefits) 588 (electronic funds transfer is required) 460 (participation agreement)
Or, you complete the same information on PECOS – Medicare’s online enrollment system.*
*This June, CMS will be launching a redesign of PECOS. If you plan to enroll, I suggest enrolling by the end of April – or wait to start once the upgrade is complete.
Medicare’s enrollment process takes 30-45 days once your enrollment application is deemed complete. If something is missing or incomplete, you will receive a letter and are given 30 days to resolve the deficiency.
There may also be a site visit. If you work mostly remotely, or in an office owned by another entity, call the Provider Enrollment department at your MAC (Medicare Administrative Contractor) to ask how to proceed. Site visits are a negative consequence of past fraud.
Medicare needs to ensure you are a legitimate business.
Once enrolled, your Medicare provider number will be made retroactive 30 days from the date your application was received.
To bill, hook your billing system up to send claims electronically…and off you go! (Medicare does not accept paper claims except in special circumstances).
Participating clinicians are required to:
Submit claims for clients.
Accept the Medicare allowable rate as payment in full.
Only collect deductible/coinsurance from your client. (No superbills)
Non-Participating – It’s not all that different from Participating, but with a few key features.
During enrollment, you will NOT sign the participation agreement. (CMS 460). The lack of this form is what enrolls you as non-par. Otherwise, the enrollment process is identical.
Non-participating providers are allowed to charge more. Specifically, in a Medicare
mathematical sleight of hand, 10% more. Here’s how it works. When Medicare processes your claim, they will allow 95% of the amount paid to participating providers. The non-participating clinician is then permitted to add 15%, with the total net gain, therefore, being 10%. The 15% is what is referred to as the “limiting charge” – the amount that a non-par provider can add on top of what Medicare allows.*
*Some states, such as New York, restrict the limiting charge. Contact a licensed healthcare attorney in your state.
You MUST file the claims for your client. However, you do NOT have to accept the assignment. (Accepting assignment = Medicare pays you). You are allowed to collect in full at the time of service: the Medicare allowed amount + the limiting charge. Upon receipt of a non-assigned claim, Medicare will reimburse your client directly.
Unlike with a commercial or a Medicare Advantage plan, the benefits to your client are NOT reduced if you are non-participating. However, your client’s supplement or secondary plan may not reimburse them for the limiting charge.
Still want absolutely NOTHING to do with Medicare?
Then you need to Opt-Out! Opting out is the third enrollment category.
Opting out is the simplest of all. There is a short form you file to Medicare, called an affidavit. Each Medicare contractor has one available for download on their website.
Opting out is an all-or-nothing proposition: It applies to all Medicare beneficiaries. If you currently have clients with Medicare, they will lose their benefits too – not just your new clients. Want to keep your current Medicare clients, just don’t want any more?
Tip: close your practice to new clients rather than opt out.
Opting out covers all services/procedures covered by Medicare. Opting out puts your NPI on a publicly searchable list and applies to ALL practice locations. So know this…
If you’re out – YOU’RE OUT!
You cannot be opted out in your private practice but then accept Medicare clients at a group or facility.
What if I opt out but want to re-enroll in the future?
You can! There is never a barrier to changing your status, although naturally, there are a few rules… (hey, it’s Medicare!)
For clinicians who are in their first opt-out cycle, there is a one-time “buyer’s remorse,” or Early Termination. You can cancel your opt-out enrollment within the first 90 days of your opt-out date. This is not available, ever again.
Be mindful of when your two-year cycle ends. You can only re-enroll at the end of the two years. You must re-enroll no later than 30 days before the start of the next two-year cycle.
Note for clinicians who prescribe medication: As an opt-out provider, the drugs you prescribe will ONLY be covered by Medicare if you stay enrolled with your privileges restricted to order, certify, & prescribe. This is an option.
The Private Contract
Each Medicare contractor has one of these available on their website as well. My advice is to download it, and don’t modify it except to cut & paste the verbiage onto your letterhead.
It’s important for you to know – What does it say?
A lot of things, some of which are obvious enough that I do not need to rehash them. The main points are the client,,,
agrees to pay & agrees not to file for reimbursement.
understands Medicare, Medicare Advantage, and/or supplement plans will not pay.
understands Medicare limits on charges do not apply.
understands that the services could be covered by Medicare, if obtained from a provider who had not opted out.
acknowledges this agreement is voluntary.
Do not take what’s written here as everything you need, if you want to opt-out. There is more to learn. Go to a Medicare contractor’s website to download their form – or attend the March 10 webinar!
Opt-out private contracts MUST be in writing and kept on file in your paper chart or EMR. As with anything else, if it isn’t documented – it didn’t happen.
Can I use a Good Faith Estimate instead?
NO. “Good faith estimates” do not apply to Medicare clients.
What happens if I stay unenrolled?
They don’t examine lists of licensed professionals and compare them against enrollment databases.
All it takes is one Medicare client who pays you, obtains a superbill, and then files for reimbursement. You’ll receive an extremely frightening letter.
The letter will state:
Medicare guidelines outlined in Section 1848(g)(4) of the Social Security Act, require the physician or supplier to file a claim on the beneficiary’s behalf for service(s) rendered to a Medicare beneficiary that may be covered. … Physicians … who fail to submit a claim or who impose a charge for completing the claim can be subject to sanctions and/or monetary penalties.
NOW WHAT?
DON’T IGNORE IT!
If you’re unaffiliated with Medicare and you’ve received the above letter, choose an enrollment category and get onboard. They will not prosecute you for a first offense, IFyou take prompt action. Enrolling in one of the above categories will demonstrate your compliance going forward.
Warning: You may be required to refund fees collected from your client(s) for sessions that didn’t follow Medicare’s rules.
A patient comes to you, says I have Medicare primary and then United Healthcare. You bill in that order, but are puzzled when Medicare denies the claim with the following reason code:
CO-109: CLAIM/SERVICE NOT COVERED BY THIS PAYER/CONTRACTOR.
Now what do I do?
You are a counselor or marriage and family therapist who cannot accept Medicare. A patient starts treatment and gives you an Aetna card. Aetna pays you – but a year later they claw back the money, stating you weren’t entitled to it because your license isn’t eligible for Medicare. But when you called to verify benefits, you were told you were in network and the patient had benefits to see you.
The patient had Aetna! What does Medicare have to do with anything?
You have several patients with BCBS and are in network. However, your claims come back paid at a different (lower) rate than usual, plus a small deduction marked “sequester.” Over time, it’s added up to hundreds of dollars. You try to figure it out and get nowhere.
No one seems able to explain it and they pass me around to different departments.
You are a Medicare provider. You’ve been seeing a patient with Medicare and a supplement for years. Suddenly, Medicare denies your claims, stating they aren’t the correct payer. You don’t understand.
How can someone have Medicare, stay retired, but then suddenly have something else for insurance?
WHY do they make this so confusing?
The one thing that all these scenarios probably have in common is that the patient may have what’s known as a “Medicare Advantage” policy.
The mental health community is often confused about what Medicare Advantage is and isn’t – so Your Billing Buddy is going to set you straight, because it often seems like no one else will.
In brief, without any technicalities, judgments, or public policy justifications/disputes for the existence of the Medicare Part C program (AKA Medicare Advantage) … these are alternative commercial plans that Medicare beneficiaries are allowed to choose. Once enrolled in Medicare Advantage, any claims to Original Medicare will deny with the above reason code that Medicare is not the correct payer.
(An exception – because there must always be one, right? – If your patient is hospice enrolled, you will go back to billing Original Medicare, with a hospice modifier).
That was about 26 million people – so if you haven’t yet seen one of these common scenarios in your practice, you will. It’s only a matter of time, especially given the aging demographics of the population.
So how do I protect myself from denials, clawbacks, and fee erosion?
There are only two things you need to do to avoid the tricky trap of Medicare Advantage:
Get their Insurance Cards
After 24 years as a biller for mental health services, I’m still shocked by how many providers (and their EMR systems) do not feel it necessary to capture this information. Insurance cards have all sorts of logos on them that provide valuable information.
All Medicare Advantage cards are easily identifiable. Terms such as Medicare Advantage, A Medicare Private FFS Plan (fee for service), or [Payer name] Medicare are usually prominently displayed. Also, look out for cards marked Dual and/or SNP – these are Medicare Advantage plans for patients who are also eligible for Medicaid and combine both benefits into one policy.
Some examples (there are many)
Verify Eligibility
Read the fine print of the section that shows you the funding source of the plan. (Although a card like the above would tell you all you need to know).
So ok, they have Medicare Advantage. Now what? Can I take this plan?
But: You do NOT have to participate in the network of the Medicare Advantage payer offering the benefits. If you aren’t, you will be paid 100% of the Medicare fee schedule. If you signed the CMS-460, you cannot balance bill. Non-participating providers may bill up to 115% of the Medicare allowable rate, just as they can with Original Medicare.
In fact, it may be preferable NOT to contract with Medicare Advantage plans. The Original Medicare allowed amount is typically anywhere from 10-40% MORE than you would be paid if you were a participating provider in a Medicare Advantage network.
The sequester applies to reimbursement from both Original Medicare and Medicare Advantage, so while it is not part of the reason why Medicare Advantage plans pay less, it is a clue that your patient with a commercial plan in fact has Medicare Advantage.
Caution: there are Medicare Advantage plans that do not offer out of network benefits – so you have to verify if there is out of network coverage. Medicare Advantage patients who have no out of network benefits have the same choice as any other patients with policies not featuring out of network coverage: self-pay or choose another provider.
Original Medicare providers are under no obligation to participate in Medicare Advantage plans.
Nor do they have to opt out in order to accept a Medicare Advantage patient who wishes to self-pay. Also, no ABN is required for Medicare Advantage patients.
I find that the biggest trap of all with Medicare Advantage, is the fact that patients don’t always understand it. When they call for service, they give incorrect information, and busy practitioners without a lot of support tend to take patients at their word. Remember, your patient isn’t trying to deceive you – but this stuff is hard to understand, or you wouldn’t be reading this blog. So, understanding your patient’s plan type could save you hundreds if not thousands of dollars later in denied or clawed back claims.
By now, we’ve all heard more than we probably want to about the No Surprises Act and Good Faith Estimates. But there is another part to the whole Consolidated Appropriations Act puzzle that concerns mental health professionals.
Consolid…what?
What we think of as the “No Surprises Act” is not a law unto itself. No Surprises, along with several other healthcare provisions that will affect practices in the years to come, was bundled into a huge spending bill passed on December 21, 2020, titled the Consolidated Appropriations Act.
An interesting factoid, courtesy of the Senate Historical office: The CAA is the longest bill ever passed by Congress, to date. It tops out at 5,593 pages.
I wonder how many members of Congress actually read all 5,593 pages …
This blog concerns the tightening of provider directory regulations.
There are regulations for provider directories? Really?
Yep. And they aren’t new, either.
As of January 1, 2016, CMS became legally authorized to fine Medicare Advantage plans up to $25,000 per beneficiary if the number of errors in network provider directories exceeded a certain threshold. It doesn’t take a math major to realize that even 50% of this penalty would be a huge chunk of change out of a health insurer’s pockets.
The effect on practitioners began slowly, without much notice or fanfare. You’ve all been subjected to it, probably without ever realizing why (other than to moan about what an annoying pain in the rear it is). Services like CAQH, Availity, and the insurance payers themselves began sending around emails: VERIFY YOUR DIRECTORY ENTRY NOW.
Later, those same emails started to become more nagging, almost threatening, in tone: YOUR QUARTERLY ATTESTATION IS NOW DUE. ACT NOW TO AVOID DIRECTORY REMOVAL.
And. They. Just. Kept. On. Coming. From everyone.
YOUR DIRECTORY ATTESTATION IS DUE IN 10 DAYS. 5 DAYS. NOW. OVERDUE. ACT NOW TO AVOID BEING REMOVED FROM PAYER DIRECTORIES.
Wait, what? They can do that?
Yep.
Prior to January 1, 2022, directory suppression of providers who did not re-attest was at the discretion of the health plan. To my knowledge, most plans never suppressed names. The only plan that I have encountered which did, was United Healthcare.
At least on the national level. Some states (California, for one) did have stricter requirements prior to the Consolidated Appropriations Act.
But as of January 1, 2022, the No Surprises Act mandates:
Health plans must refund enrollees the additional costs for out of network care if they paid an out of network bill for services & can show they went out of network because of inaccurate plan directories. Yes … Really!
Health plans must pay an out of network claim with in-network level cost-sharing, if the patient saw an out of network provider due to a directory error. I would imagine that the patient would have to do some serious advocacy on their own behalf, though.
In this event (an out-of-date directory) the out of network provider must not bill the patient more than the in-network cost-sharing. No balance-billing.
Providers can require health plans to remove them from the directory at the time they terminate their contract.
Health plans must have a regular method of verifying provider directory information.
Payers must update their directory within 2 business days of receiving new information.
Payers must confirm with providers every 90 days to re-verify accuracy of information.
Payers must suppress provider information from directories if attestations aren’t received every 90 days. (Note: suppression does not affect claims for ongoing patients. Those will still be paid at the in-network rate. It’s the online directories that will not list your name. Maybe you don’t care …. But if an existing patient changes insurance, only to consult their new directory and discover that you are no longer listed…then what?)
Certainly, the need for accurate directories is important. Nor would verifying, or attesting, be a huge problem on the provider side, if a way existed for providers to go one place once per quarter and disseminate the same information to all plans. (Wasn’t that the original point of CAQH?) The burden comes with having to go multiple places online to provide the same information, take phone calls, fax or email forms. It’s a burden even for providers who have staff – because employees must be paid. This is employee time that could be devoted to patient care or billing.
Trying to figure out how to get paid for telehealth? *
*Doing audio-only? Coding and policies for audio-only telehealth are different. This blog focuses only on two-way audio/video telehealth.
If you thought it was bad in 2021, when you just had to deal with whether to use Place of Service (POS) 02 versus 11, and modifier -GT versus -95, now there’s a new complication.
Announced by CMS on October 13, 2021, the new place of service code (POS) for telehealth is 10, and it indicates telehealth when the patient is receiving services at home. Meanwhile, POS 02 has been shifted to denote that the patient is somewhere other than at home.
Don’t ask me why they felt it was necessary to make this distinction…
Next year, there will be a place of service for the bathroom.
When announcing the new POS 10, CMS originally stated that the implementation date for Medicare was April 4, 2022. However, the renewal of the Public Health Emergency (PHE) on April 13, 2022, trumps Medicare’s implementation of POS 10, because, according to the emergency waivers issued at the start of the COVID-19 pandemic, the telehealth flexibilities put in place as of March 6, 2020, will last until the end of the PHE (currently set for July 15, 2022).
Note: Medicare will pay for POS 10 (and 02) during the PHE, but coding POS 02 or 10 will impose a rate reduction.
This is because according to pre-pandemic Medicare telehealth policy, telehealth was subject to fee reductions. Medicare instituted the COVID telehealth billing flexibilities so as not to have to reprogram their payment systems, and also to ensure that healthcare providers could stay in business – sort of an important consideration during a worldwide pandemic.
What about commercial payers?
That’s the problem. Unlike Medicare and other government payers for whom billing instructions are a matter of public record, private payers don’t always openly disclose what they expect regarding telehealth coding – or they do, but it is often unclear, incomplete, and/or they make it so hard to find that it takes hours of searching.
Why is this so difficult? I just want to know how I can get paid for telehealth! Why can’t they all agree on how to bill it?
If I had the answer and solution to this problem, I would be able retire to Bora Bora tomorrow and you would have to find another Billing Buddy.
It’s frustrating, but right now everything depends on the payer and the policies they have implemented with regard to billing for telehealth. Some payers simply follow the lead of CMS. Others do their own thing…and they aren’t always consistent about it, either.
Your Billing Buddy’s recommendations for commercial payers:
Check the payer’s website to see what (if any) instructions exist regarding billing for telehealth. I typically start by looking at the links marked “COVID-19” and then clicking around randomly until I get to information about telehealth and, hopefully, information about how to bill it.
If you DO find something definitive, print it out. This will give you a snapshot of the date you obtained the information. Save it – you never know when you might need it in case of a clawback / recoupment attempt.
Maintain a log or spreadsheet of the telehealth billing policy / coding requirements of the payers you bill most often.
If you have time, feel free to call the payer, just don’t be surprised if it takes you a long time on the phone and at the end of the call you are more frustrated (but no more enlightened) than you were an hour or two previously.
Subscribe to payer newsletters, blogs, and watch for webinars and trainings they offer.
When in doubt, stick with POS 02 as long as the PHE remains in effect.
If am unsure whether POS 10 is acceptable yet, but think it appropriate to try, I send in one test claim. I make note on my spreadsheet of the patient account #, date of service, and date submitted. Then, before submitting any more, I wait until it is adjudicated. Once I have my answer, I correct and release the remainder of claims that I have put on hold. That way, if the claim does get denied or underpaid, a single claim can be corrected quietly, without a large number of claims needing correction.
w it works. When Medicare processes your claim, they will allow 95% of the amount paid to participating providers. The non-participating clinician is then permitted to add 15%, with the total net gain, therefore, being 10%. The 15% is what is referred to as the “limiting charge” – the amount that a non-par provider can add on top of what Medicare allows.*
Then you need to Opt-Out! Opting out is the third enrollment category.
DON’T IGNORE IT!
