Massachusetts Speech-Language Hearing Association
  • 23 May 2017 11:11 AM | Barbara Wilson Arboleda (Administrator)

    Our Medicare Administrative Contractor, National Government Services (NGS) has been developing a number of resources for providers over the past several years. The most recent is this great How To video for checking eligibility. They even include information about finding the contact numbers and addresses for the various Advantage plans that your patients may be subscribed to. It's only about 5 minutes long and definitely worth the watch!



  • 04 Apr 2017 3:25 PM | Barbara Wilson Arboleda (Administrator)

    Many speech-language pathologists have questions about the decision to enroll in Medicare. Should you? If so, what participation status should you choose? The following article is designed to answer these basic questions and a few others about Medicare enrollment.


    Enrollment is Mandatory

    Since July 2009, speech-language pathologists have been allowed to enroll as independent providers for Medicare. This was an important milestone in the development of our profession, as it reflected the recognition of speech-language pathology as a skilled professional medical provider. There are pros and cons to every change in our professional lives, however. One result of our acceptance as a profession worthy of provider status was that Medicare enrollment is not optional if we want to provide covered services to Medicare beneficiaries. A few categories of professional have a process by which they can "opt out" of Medicare. Speech-language pathologists are not among those professions. 


    It is important to recognize the necessity of enrolling in Medicare prior to seeing any Medicare patients - which are virtually all patients who are over the age of 65 and also a number of disabled younger patients. The law prevents speech-language pathologists from 1) entering into private contracts with patients for covered services; 2) setting their own rates for Medicare beneficiaries for covered services; 3) using an Advance Beneficiary Notice to avoid billing Medicare for covered services. 


    Two "Participation" Options

    The good news is that you can choose between two options regarding the way in which you interact with Medicare. 


    Participating Providers:

    These providers provide the service and bill Medicare directly as with any insurance company. The 20% co-payment is collected either at the time of visit or after the Medicare and supplemental insurance claims have been processed. Participating providers must accept "assignment" (meaning the amount listed in the Medicare fee schedule) as complete payment for the services rendered. The upside to this is that the patient at most has to pay the 20% co-payment at the time of service. The downside is that the provider is liable for denials and appeals.


    Nonparticipating Providers:

    These providers are subject to maintaining the same documentation as all Medicare providers, but they give the necessary paperwork to the patient for them to file with Medicare and then subsequently with any supplemental insurance policies that they have. The patient must pay for the service at the time of the visit. The fee amount is limited to 115% of 95% of the Medicare fee schedule amount or your customary and usual charge, whichever is lower. 


    Individual providers can decide which participation option to choose. If you are working in or own a group practice, all providers in the practice must have the same participation status.


    "Incident to" billing

    The only circumstance under which a speech-language pathologist can see Medicare patients without being enrolled in Medicare is if they are billing "incident to" physician services. This may sound like a better option than it really is. There are two major downsides to this arrangement 1) the "supervising" physician must be on site during all services provided to Medicare beneficiaries by the speech-language pathologist; 2) it undermines our hard-won professional status by implying that we are merely ancillary assistants to physicians who are in need of supervision in order to do our work.


    Clinical Fellows

    In states where Clinical Fellows are licensed or registered, they are able to enroll in Medicare and treat patients in the same way as any other speech-language pathologist. In states without Clinical Fellow licensure, they are subject to the same supervisory requirements as graduate student clinicians (meaning in-the-room supervision by the licensed clinician). It is not legal to bill "incident to" a speech-language pathologist. Therefore the Clinical Fellow is not allowed to bill under the National Provider Identifier (NPI) or license of the supervising speech-language pathologist.


    Just do it...

    Enrollment is free, although there is a significant amount of documentation required. Nonetheless the process is now fully electronic. Remember, if you are not enrolled as a Medicare provider you may not see Medicare beneficiaries for covered services 1) even if they want you to; 2) even if they say they want to pay out of pocket. 


    How to Enroll

    First, you'll need to obtain an NPI number. If you own a practice, you'll need to get both an organizational and an individual NPI. You can register for your NPI here: https://nppes.cms.hhs.gov


    Then you need to sign up for PECOS (the Medicare Provider Enrollment, Chain and Ownership System) and fill out the application here: https://pecos.cms.hhs.gov. Medicare has produced a video to help you know what to expect: https://www.youtube.com/watch?v=swNrOWgdcnY


    And of course there are great resources on the ASHA web site. My favorite right now is the Medicare Survival Guide for Audiologists and Speech-Language Pathologists. You can buy it in the ASHA Store here.


  • 14 Jun 2016 6:37 PM | Barbara Wilson Arboleda (Administrator)

    When speech-language pathologists became eligible to sign up as independent providers with Medicare in 2009, it was a mixed blessing. Many people worked for years to ensure that speech-language pathologists would be recognized as the highly trained, licensed professionals we are. Obtaining the ability to bill Medicare under our own provider numbers finally cemented our professional status as health care providers within their system.


    Inevitably, the ability to enroll in and bill Medicare, however, came with a number of obligations and restrictions. Now that we can be Medicare providers, we must be whenever providing services to a Medicare member (see my previous post on the lack of an opt-out option for speech-language pathologists). In addition, the paperwork involved in joining Medicare can be somewhat overwhelming at first.


    Some speech-language pathologists are forgoing Medicare provider status, opting to bill their work as “incident to” physician service instead. While this is a legitimate, legal option for Medicare billing, it has implications for speech-language pathologists as independent health care professionals and I believe in the end it endangers the professional recognition we have worked so hard to achieve.


    So, what is "incident to" billing? 


    "Incident to" billing occurs when a health provider (such as a speech-language pathologist) is paid by a physician to provide services that are then billed by and under the NPI of the physician. Under this system, the speech-language pathologist does not have to be an independent participating provider with Medicare and in fact does not even need to have a license (though they must meet other criteria for speech-language pathology provider status). 


    This sounds like a great work-around to the hassle of obtaining Medicare provider status, but there is a huge trade off. Under the "incident to" model, the therapist needs to be under the "direct supervision" of the physician during all of their work. This means that there must be a physician in the office suite whenever the speech pathologist is working with patients. If the MD you're working for goes to a conference for a week, you can't see patients. 


    In addition, the supervising physician must be immediately able to come in to "help" whenever needed.  They also must "take responsibility" for the treatment provided. The entire system is designed around the concept of the treating provider being a dependent, para-professional who is not allowed to provide treatment without the presence of a physician. Unfortunately, if substantial numbers of speech-language pathologists decide to forego independent provider status and submit to the "direct supervision" requirements inherent to an "incident to" billing status, Medicare may reconsider their decision to allow us to become independent providers. Widespread use of "incident to" billing is a threat to the gains we have made as a profession to prove our inherent worth.


    As a speech-language pathologist, you can still be hired by a physician practice, bill under your own provider number and then “assign” your payment over to the practice. That allows you to take advantage of the benefits of being employed (where someone else is dealing with the hassles of billing), while maintaining your professional status and autonomy. 


    "Incident to" billing certainly has a place within the big picture of the healthcare structure. It was useful in allowing me to work with two physician groups when I was in private practice to provide stroboscopic examinations to their patients. For the day-to-day operations of evaluating and treating speech-language disorders, however, an "incident to" arrangement invariably leads to a hobbled ability to effectively execute your professional autonomy. This bears consideration before deciding that becoming a Medicare provider is too much trouble. What's a few hours more of paperwork if it gives you a career of greater self-determination?


    Reference:

    Medicare Benefit Manual

    230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident To the Services of Physicians and Non-Physician Practitioners

    (Rev. 179, issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14 


  • 01 Mar 2016 12:14 PM | Barbara Wilson Arboleda (Administrator)

    Many of us in speech-language pathology and audiology recall the enthusiasm of 2009 when we finally achieved the ability to obtain provider status with Medicare. For some, this became a mixed blessing due to the fact that neither speech-language pathologists nor audiologists were given the ability to “opt out” of Medicare provider status. The ability to be a provider with Medicare became an obligation to be a provider with Medicare in order to provide treatment to Medicare beneficiaries.


    The speech-language pathologist or audiologist who is not aware of this restriction can easily run afoul of the law in this regard and could end up in a boatload of trouble. The purpose of this post is to outline the basics of the opt out rule and how to navigate the restrictions presented by not being able to opt out of Medicare provider status.


    Certain providers are allowed to “opt out” of being Medicare providers. These include physicians, physician assistants, nurse practitioners, clinical social workers and clinical psychologists among others. When a provider opts out of Medicare, they must send formal notice to CMS that they do not intend to participate. There is a contract that is signed between the provider and each Medicare beneficiary they treat stating that neither the provider nor the patient will submit a bill for the services to the Medicare program and the patient pays the provider for the services directly.


    Neither speech-language pathologists nor audiologists are allowed to do this. So if you have been operating under the belief that you can opt out and sign a contract or an ABN with your patients for private treatment, you must stop. You are putting your professional livelihood at great risk if you continue.


    So, what can you do if you don’t want to process Medicare claims yourself, but you want to treat the elderly population, most of whom are Medicare beneficiaries?


    The first piece of information that is helpful to understand is the distinction between provider enrollment and the payment relationship of the provider to Medicare. When enrolling as a provider with Medicare, you have the option of enrolling as a “participating” or a “non-participating” provider. A participating provider treats the patient, bills Medicare directly and receives payment directly from Medicare as well. A non-participating provider is paid up front by the patient and the patient submits the charge to Medicare. As long as you are enrolled as a Medicare provider, you are allowed to see Medicare beneficiaries as a non-participating provider.


    This sounds like the best of both worlds, right? Before you go celebrating too much, it is important to know that a non-participating provider is still restricted in terms of what they are allowed to bill for services. A non-participating provider is only allowed to charge up to 115% percent of the “allowable” charge for the service provided, if they do not accept “assignment” from Medicare (that is to have Medicare pay you directly) and if the providers “usual and customary charge” is at least that price. If the provider accepts Medicare assignment, the provider is only allowed to charge 95% of the allowable charge. The patient pays 20% of this and the rest is paid by Medicare. Both participating and non-participating providers must follow Medicare regulations regarding documentation and certification.


    Each clinician will have to decide for themselves whether to be a participating or a non-participating provider. Fortunately, if you are a part of a group practice each provider can still choose to be participating or non-participating independently of the others in the practice. Every provider who treats Medicare patients must enroll as a Medicare provider, however, in order to be in compliance with Medicare regulations.


    Special thanks to Kate Ogden, Health Policy Associate at ASHA, for her guidance and clarifications in preparing this post. 


    CMS guidance for calculation of non-participating fees can be found here: 

    www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf


  • 18 Dec 2015 4:20 PM | Barbara Wilson Arboleda (Administrator)

    Welcome to the MSHA Reimbursement Blog! My name is Barbara Wilson Arboleda, MS CCC-SLP and I am the new State Advocate for Medicare Policy (StAMP). This is a joint MSHA/ASHA position which purpose is to help keep the clinicians in our state informed as to Medicare policies and regulations.


    The first topic I have been asked to address is in regard to the pending legislation H.3879 “An Act Providing for Provisional Licensure for Speech-Language Pathologists”. There remains a great deal of confusion regarding the status of Clinical Fellows in our state and the reasons why we need to have this legislation passed.


    Many years ago, it was acceptable for speech-language pathology practices and clinics to hire Clinical Fellows and bill for their services under the license number of the supervising speech-language pathologist. Over time, however, payers have become more restrictive in terms of who they will allow to see their patients and bill for speech-language pathology services. At this point most payers, including Medicare, will not accept a non-licensed clinician providing skilled services to their members.


    The key to understanding this issue is remembering that the Clinical Fellow is an ASHA designation for a person who is in the process of earning ASHA’s CCC, but the matter of licensure is a separate matter. The Clinical Fellowship program is overseen by ASHA. Licenses are issued by the State. In states where no license is provided to Clinical Fellows, Medicare (and many other payers) considers that fellow to be a student for the purposes of seeing patients and billing. In regard to Medicare Part B, that means in-the-room supervision with the licensed clinician directing the session and not involved in seeing another patient or in other tasks.


    To clarify this difference further, it is not illegal to be a Clinical Fellow in the state of Massachusetts. The licensure law clearly makes provisions for the activities of a Clinical Fellow who is properly supervised. What the licensure law does not do is say that anyone has to pay you for those services provided by a Clinical Fellow. Therefore, Clinical Fellows are in a somewhat untenable situation.


    Massachusetts is actually late to the game in recognizing this problem. We are only one of eight states left in the country that does not grant licensure during the Clinical Fellowship period. There is a great deal at stake in terms of ensuring passage of H.3879, including the fact that there are certainly clinics out there who continue to hire based on the old rules, unaware that anything has changed. The risk that these clinics are open to is enormous. In addition, we continue to lose some of our best and brightest students to other states where there is more varied opportunity open to them – particularly those who are interested in working in the healthcare sector.


    At this time, H.3879 resides with the “Joint Committee on Healthcare Finance”. From there it will hopefully be recommended forward for a vote in the legislature. Those of us who have been involved in the development of this legislation are working hard to ensure that it will be passed in time to benefit the current graduating class of students.


    We can’t afford to wait any longer to join the rest of the country in giving Clinical Fellows a license to practice during their fellowship. A letter to your local Representative or state Senator stating your support for this bill will help resolve this conflict, keep our Clinical Fellows in the state and bring many clinics into compliance with current Medicare regulations. I hope you will join us in urging its passage. 


Massachusetts Speech-Language Hearing Association
465 Waverley Oaks Road, Suite 421, Waltham, MA 02452
Phone: 781-647-7031
theoffice@mshahearsay.org
       
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