Dazed and Confused: Medicare, Direct Access, Particpation and the Trouble

with Opting OutKim Cavitt, AuD

Audiology Resources, Inc.

Medicare Participation

• Participating Provider– Agree to accept Medicare allowable as payment in full (assignment)– Reimbursement is 5% higher than non-par– Listed in provider directories– Automatic crossover to secondary insurer

• Non-Participating Provider– Medicare non-par allowable is 95% of the Medicare par allowable– The limiting charge is 115% of the Medicare par allowable– Not listed in directories – Does not automatically crossover to secondary insurer

• Free for All (and not the Ted Nugent Song)– You do no charge any patient for diagnostic testing under any circumstance

• Opt Out– Audiologists are not allowed to opt out of the Medicare system and enter into private

contracts with Medicare beneficiaries

Medicare Coverage

• Medicare COVERS items and services which are medically reasonable and necessary to diagnose a medical or surgical condition– Medicare does not cover treatment or

rehabilitation that is provided by an audiologist• i.e. vestibular rehabilitation, aural rehabilitation, tinnitus

management, APD therapies, cerumen removal

• BUT, because these treatments are within our scope of practice and licensure, audiologists may provide these services to their patients and collect payment from the patient for these non-covered services

Physician Order

• For an item or service to be COVERED by Medicare, audiologists must have a physician order from the patient’s physician prior to the service being rendered– No order, no coverage (the procedure would

become the financial responsibility of the patient)

Physician Order

• Written

• E-mail

• Phone

• The presence of an order DOES NOT guarantee medical necessity

Direct Access

• This would eliminate the need for the physician order– Medical necessity will still need to be met– FDA guidelines for hearing aid dispensing

would still need to be followed

Medicare Regulations

• Update to Audiology Policies– Effective October 1, 2008

• Revision and Reissuance of Audiology Policies– Effective August 1, 2010

• http://www.cms.gov/PhysicianFeeSched/50_Audiology.asp#TopOfPage

Local Coverage Determination

• “Local coverage determinations (LCDS) are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states: "For purposes of this section, the term 'local coverage determination' means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).”– http://www.cms.gov/DeterminationProcess/

04_LCDs.asp#TopOfPage

Local Coverage Determination

• These can restrict payment and coverage by diagnosis, clinical situation, and/or medical necessity

• Non-coverage means the item or procedure becomes the financial responsibility of the patient– Need a signed ABN

Questions?

• I answer questions for 60 days free of charge for ALL attendees

• ADA members can contact me at any time with questions– It is a value added benefit of your ADA

membership

• My contact information:– Email: kim.cavitt@audiologyresources.com– Phone: (773) 960-6625 (cell)