Health insurance providers, public health institutions, and other payer entities typically cover most medical services and treatments administered by physicians, clinics, and hospitals. This also includes things like most prescription drugs, wellness care, and even patient-use medical devices. Yet a lot of medical billing companies recognize that private payers and institutions like Medicare do not always cover certain treatments, items, medications, and services.
Essentially a non-covered service in medical billing isn’t being covered by a government institution or private payers.
What Are Medicare Non-Covered Services
The covenants and regulations that guide the Medicare health system have a few non-covered services that medical providers need to be aware of. This includes:
- Medically unreasonable or unnecessary treatments and supplies
- Services and items that are not specifically covered in the patient’s treatment plan
- Services and supplies denied as part of a bundle
- Supplies and services that are not included in the basic allowance of another service
- Items and services that can be reimbursed by other organizations
- Items and services that can be furnished by another organization without charge
- It is also worth noting that Medicare doesn’t cover services and supplies that are not considered to be medically necessary to diagnose and treat the patient’s condition. This may include things like:
- Hospital furnished services that could have been furnished in a lower-cost setting, such as the patient’s home or a nursing home care facility.
- Hospital services that exceed the Medicare “Length of Stay Limitations.”
- Evaluation of management services that exceed those considered to be “Medically Reasonable and Necessary.”
- Excessive diagnostic procedures
- Excessive therapeutic treatments
- Unrelated screening tests and exams
- Therapies unrelated to the patient’s symptoms
- Non-related screening tests, examinations, and therapies
- Unnecessary services based on the diagnosis of the patient such as acupuncture or guided meditation
For the Medicare health system to recognize a claim the services should meet specific medical necessity requirements based on the statute, regulations, and manuals defined by National Coverage Determinations as well as Local Coverage Determinations. In a case where they do meet these regulations, the attending physician needs to clearly indicate the specific symptom, sign, or the patient complaint that deems the service reasonable and necessary.
Though there is additional information provided by Medicare Preventive Services, Transitional Care Management, Chronic Care Management, and Advance Care Planning, which states that “Medicare may cover items and services that are administered to alleviate pain or discomfort. Even if such use may increase the risk of death, if not furnished for the specific purpose of causing death.”
How Is Something Deemed Medically Reasonable & Necessary?
Medicare most often covers well-established technologies, diagnostics, treatment, and procedures. Though items and services should be proven safe and effective, to qualify as medically “Reasonable and Necessary.” This involves applying the following criteria:
- The illness or injury is consistent with the symptoms or diagnosis.
- It is considered “Necessary and Consistent” with generally accepted professional medical standards.
- It is not exploratory or an experimental
- Not provided primarily for the convenience of the patient, the attending physician, a specialist or other physician, or a third-party medical vendor.
- That the procedures are furnish at an appropriate and applicable level that can be provided safely and effectively to the patient.
Services That Medicare Doesn’t Cover
The health plan benefits can differ depending on the patient’s needs, and the applicable state regulations. To help prevent claim denials, claim rejections and claim delays it’s advised for physicians to check their Medicare carriers’ website to stay informed on the most up to day exclusion policies. Though some services aren’t covered by most health plans, which includes the following:
When it is performed merely to improve the patient’s appearance, without necessarily addressing a functional defect.
This includes treatments, dental filling, tooth extractions, dental implants, or treatments that alter the structures directly supporting the teeth.
This includes conditions like flat feet, supportive devices for feet, as well as hygienic and preventive maintenance foot care.
This includes examinations for purpose of fitting, prescribing, or changing hearing aids.
This is associated with long-term care services and support that go beyond 80 to 100 days.
Routine Physical Check-Ups
This includes things like eye exams for prescribing, fitting, or changing eyeglasses, as well as various screenings, and vaccinations that are not specifically covered by a prevailing statute.
Personal Comfort Items & Services
Things like therapeutic pillows, padding, and special seating.
These are not a part of an active or ongoing diagnostic process.
How To Collect Payment For Non-covered Services
The current rules applied by Medicare make it possible for a physician or other medical provider to bill the patient for services that are not specifically covered by Medicare. Though this is based on whether or not the patient requests a service that Medicare that is not deemed to be medically reasonable and necessary.
At the same time, the payer’s website should be checked for coverage information on that specific service. The physician should then notify the patient before providing the diagnostic, treatment or service, to ensure that the patient recognizes that they are responsible for the payment as an out-of-pocket expense.
As a standard practice in the billing process, the patient should be provided written notice which is known as an Advanced Beneficiary Notice of Noncoverage. This helps the patient to make an informed decision about whether to get the service and also notes that they accept responsibility to pay for it out of pocket even if Medicare doesn’t pay.
An Advanced Beneficiary Notice of Noncoverage document needs to include the following:
- An accurate and easy-to-understand the description of the item or service being provided.
- The specific reasons why Medicare might not pay under current guidelines.
- An accurate estimate of the out-of-pocket costs for the item or service the patient will be responsible for.
Failing to obtain proper patient consent via an Advanced Beneficiary Notice of Noncoverage document can terminate the physician’s right to bill the patient for non-covered services. In legal terms, it could be regarded as a violation of the applicable payer agreement.