Medicare Compliance & Reimbursement

Question: Can a practice send a Medicare beneficiary an advanced notice of noncoverage for a service that Medicare actually covers? One of the providers at our practice thinks the payment rate for a certain procedure is too low through Medicare and knows the patient can afford to pay cash.

AAPC Forum Participant

Answer: If the provider is participating as a Medicare provider — no.

In the Medicare Learning Network (MLN) booklet “Medicare Advance Written Notices of Non-Coverage,” the Centers for Medicare & Medicaid Services (CMS) specifically says that participating providers cannot transfer payment liability to a patient if Medicare covers a service.

CMS says there are several situations in which a provider cannot issue advance written notice of noncoverage, including situations where service claims are denied due to a Medically Unlikely Edit (MUE), situations where a provider wants to charge a patient for part of a service Medicare pays through a bundled payment, or situations where liability is transferred to a patient when Medicare would pay for items or services.

Find more information at www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/abn_booklet_icn006266.pdf.