One of the more difficult insurance areas to navigate is Medicare. This isn't because it's complicated, it actually follows very straightforward guidelines. The difficult part is gathering the correct information! This week, we're going to break down the Centers for Medicare & Medicaid Service (CMS) guidelines for Medicare and Medicaid patients and show how this information may impact your ability to see patients covered under these plans.
Who is eligible?
Nutritional counseling is an eligible service. Accordingly, when Healthy Bytes processes eligibility checks for a patient covered by Medicare, we make sure that the patient’s plan is active and whether there have been any visits used.
A diagnosis from a physician is also a very important factor, as only patients who have diagnoses of diabetes and/or renal diseases will be covered. This means that all patients also require referrals from primary care providers in order to utilize these services.
If a patient is covered by a secondary plan, it’s important to note that even secondary plans often follow Medicare guidelines. Therefore, if Medicare rejects a claim based on CMS guidelines, the secondary insurance will likely reject it as well. However, as long as you follow the information we give you below, this shouldn't be an issue!
A key factor in working with patients with secondary plans is that you, as a provider, still need to be contracted with Medicare in order for the patient to see you.
What do patients get?
Well, each patient is covered at 100% of the Medicare allowed amount as long as he passes certain requirements. These services, as long as they are rendered by a contracted provider, are not subject to deductibles, out of pocket maximums, co-insurance, or co-pays. This means the patient will not have to pay anything at the time of the visit. Remember, the allowed amount may differ from (and could be less than) your hourly rate. It is illegal to charge the difference between your usual practice rates and Medicare's allowed amount. Once the insurance company approves and pays for a claim, that is the final amount allowed.
How much time can I spend with these patients?
Medicare and Medicaid plans generally run on a calendar year. If a patient is in the initial year of his plan, meaning that his plan has never paid for nutritional counseling for him, the patient is covered for a total of three hours per year. For any subsequent years, the patient is limited to two hours of counseling. As the provider, you are able to decide how to spread out these hours, as long as they’re conducted in increments of 15 minutes. Visits must be one-on-one counseling sessions and rendered in your office.
If you feel that your patient requires more time, fear not! It is possible to extend these limits, though it is not a guarantee. Patients' primary care physicians can verify changes in health status or treatment plan and issue a new referral. Medicare will then decide whether to cover additional visits.
More information can be found on the CMS website and, of course, by contacting us at Healthy Bytes!