Medicare/Medicaid
CHANGES IN MEDICARE ADDRESSED
Recent changes in Medicare payment policies that focus on medical necessity and its supporting documentation have put both physicians and the hospital in an uncomfortable position. The Department of Health and Human Services (DHHS), Office of the Inspector General (OIG) has taken the position that a physician who orders medically unnecessary tests may be subject to civil penalties on federally funded patients. Only tests that are medically necessary for the diagnosis and treatment of the patient will be reimbursed by federally funded insurance plans, i.e., Medicare.
You are, of course, still free to order any tests you judge appropriate for an individual patient's treatment. If the fiscal intermediary considers that these tests are not medically necessary, the patient (the beneficiary) must sign a Notice of Non-Coverage or an Advanced Beneficiary Notice at the time the procedure is ordered. This waiver acknowledges that the patient understands that Medicare may not pay for this service and will assume responsibility for it. Detailed information about medical necessity can be obtained from the DHHS, the local intermediary.
To determine the medical necessity of a test or procedure, the fiscal intermediary requires the ordering physician to document a diagnosis with an ICD-9 diagnosis code. This requirement of the Balanced Budget Act of 1997 went into effect January 1, 1998. In addition, Medicare has strongly encouraged laboratories to review annually the most frequently ordered test so that labs can monitor growth of tests orders. If the reason for the growth of test orders is other than the addition of new patients or physicians, steps to detect and correct any fraud and abuse must be implemented.
To facilitate in obtaining the waiver Wayne Hospital utilizes the Care Medic System Inc. LMRP software. With this new program diagnostic information provided with the test request will be checked to determine coverage. If no information is provided or the information provided does not meet LMRP coverage guidelines the physician will be contacted to determine if there is any additional reason for testing. If there is no additional information the patient will be informed that the testing is not covered and that they will be responsible for payment. They will then be asked to the sign the waiver agreement.
Both the Medical Staff and the Hospital work together to provide quality care for our patients. Another critical goal is to follow the Medicare regulations to prevent abuse and avoid the civil penalties for the noncompliance while at the same time recovering all allowable costs for the services we render to our patients. As further information becomes available from Medicare, we will continue to keep you abreast of the steps we must all take to achieve these ends. Your continued cooperation is both valued and necessary.
ATTENTION MEDICARE PATIENTS
Does your doctor visit today include laboratory tests, x-rays, or other diagnostic testing?
IF IT DOES, YOU NEED TO KNOW ABOUT AN IMPORTANT CHANGE:
Recent changes in interpretation of the Social Security Act affect the way Medicare views Routine and Screening tests. When the doctor suggests or orders laboratory tests, x-ray, EKG, or other diagnostic tests, Medicare will pay for only the services that it determines to be "reasonable and necessary." If Medicare determines that a particular service, although it would otherwise be covered, is "not reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service.
You will be responsible for the services that Medicare denies