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  • 1.  AUC GUIDELINES AND CASH PAY MEDICARE PATIENTS

    Posted 03-13-2020 20:29

    ​Hello,

    Had an interesting question from a referring physician about AUC and the Medicare patient who requests to pay cash for their exam when it is not medically necessary according to AUC guidelines.

    If the referring physician writes the referral, but patient pays cash at time of service and no billing occurs from the imaging center, will the referring physician be penalized (assuming there are penalties come 2021) in anyway?

    Thank you,



    ------------------------------
    Lisa Ford
    Director of Business Development
    HALO Dx
    Indian Wells CA
    (760) 776-8989
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  • 2.  RE: AUC GUIDELINES AND CASH PAY MEDICARE PATIENTS

    Posted 03-14-2020 06:43
    Hi Lisa
    The federal law (PAMA 2014) requires that the treating clinician's decision on what to order is the final word, even if it is "does not adhere". We often say "there is no hard stop" in the law.
    The PAMA language also requires that the Medicare agency must set up a process for tracking those clinicians who are way out of bounds on their ordering. This will only include the 5 percent who are exceptionally out of bounds on all of their ordering patterns.  However, these "outlier" regulations have not yet been written and likely won't be for sometime. 

    My recommendation is that, at this time, clinicians should order what they believe is best practice and not worry about what may come in the future until we see those draft regulations. I'm sure RBMA will comment on anything we believe is unreasonable.

    Thanks
    Liz Quam



    Original Message


  • 3.  RE: AUC GUIDELINES AND CASH PAY MEDICARE PATIENTS

    Posted 03-14-2020 11:13

    Here are my thoughts:

    1. Medical Necessity is determined by LCDs and NCDs, not by the forthcoming AUC requirement.  Thus, it is not possible to determine medical necessity through an AUC consultation, even when the consult fails to adhere to the criteria. 
      1. The AUC and LCD/MCD may agree, they may not, but in any case, one can't determine Medical Necessity using an AUC consults.
    2. I'd caution everyone against NOT billing exams that that are "covered services" because they don't meet medical necessity then collecting from the patient
      1. Medicare requires providers to file claims whenever they perform a covered service on a Medicare beneficiary. 
      2. In the example discussed below the service seems to be a "covered service which did not meet the medical necessity guidelines
      3. In this case, the provider should obtain an ABN because the reason for the exam did not meet medical necessity, then file the claim with a GA modifier indicating the provider has an ABN. 
      4. Medicare will deny the claim but indicate the patient is responsible for the allowed amount. 
    3. The only time filing claims is optional is when the provider performs a service that is excluded from the Medicare program (i.e., a  non-covered service).

     

    In this case discussed below, the provider seems to be providing a "covered service" which does not meet medical necessity.  The provider should file the claim with a GA modifier, wait for the denial, then balance bill the patient.

     

    Mike Bohl

     




    Original Message


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