Access the Medicare MNT benefit

Access the Medicare MNT benefit

For appropriate beneficiary access to the Medicare MNT benefit, dietetic professionals should establish a system for accepting referrals. The four components of accepting a referral include: verify eligibility, comply with Medicare Secondary Payer (MSP) regulations, communicate the Beneficiary's Medicare Benefits, and complete of referral documentation.

1. Verify Eligibility Background: Entitlement and Eligibility

  • Coverage for Medicare Part A is automatic after an eligible person has filed an application for Medicare through Social Security and meets certain coverage criteria.
  • Coverage for Medicare Part B is optional. It is purchased by the beneficiary through monthly premium payments.
    • A beneficiary may be entitled to Part B benefits. In order to utilize benefits, the beneficiary must also be ELIGIBLE for benefits in addition to being ENTITLED.
    • Keep in mind, even with eligibility and entitlement, a beneficiary's utilization of the Medicare MNT benefit also depends on establishing medical necessity for the services provided.
    • Therefore, to qualify for Medicare Part B benefits, a beneficiary must:
      • be enrolled in the Medicare Insurance-Part B program, and
      • require the services

Practice Tip:

  • All persons entitled to Medicare benefits are issued Medicare cards to show the type of benefits to which they are entitled. It is IMPORTANT to get a copy of the actual Medicare card before providing the service and to use the information exactly as it appears on the card to ensure accurate and timely billing of services. If you are photocopying the Medicare card, make sure the copy is readable.
2. Medicare Secondary Payer (MSP)

Even in situations where the beneficiary has legitimate Medicare coverage, Medicare is not always the primary source of payment. Medicare becomes the secondary payer (MSP) when another payment source is identified as having primary responsibility for paying a beneficiary's medical expense. (Refer to Medicare and Other Insurance Coverage accessible by visiting ADA member-only pages; Click to main tool bar "Policy Initiatives & Advocacy" and then to "MNT" left-hand side bar.)  Compliance with MSP regulations is critical to the providers continuing participation in the Medicare Program. Failure to maintain a system of identifying other payers is viewed as a violation of the provider agreement with Medicare.

  • MSP situations must be identified for every encounter so that the correct primary payer can be billed from the start.
  • Even if a primary payer's coverage is exhausted, Medicare is still the secondary payer. Most likely, Medicare will process and pay the claim after you've sent a copy of the denial letter from the primary insurer.

What are the penalties for non-compliance?

  • Failure to indicate on a Medicare claim that a patient is covered by a primary insurer, can results in PENALTY and no Medicare payment will be made.
  • Knowingly, willfully, and repeatedly providing inaccurate information relating to the availability of other benefit plans can result in PENALTY — Up to $2,000 in civil penalties for each occurrence.
  • Failure on the part of insurers to pay primary to Medicare can lead to PENALTY — Double Damages

Practice Tips:

  • Complete an MSP screening form/beneficiary questionnaire (see attached) for each Medicare Beneficiary. It is the providers' responsibility to identify when an MSP situation exists. Each question listed on the MSP screening form may not apply.
  • For a paper claim to be considered for Medicare secondary payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.
  • When a practitioner files a secondary claim, he/she should always attach a copy of the primary claim's EOB to the claim form. To prevent violating confidentiality laws, practitioners should take a black marker and black out the other names on the EOB before filing the secondary. This may prevent a patient from filing a confidentiality lawsuit.

3. Communicating the Beneficiary's Medicare Benefits

One of a practitioner's most important responsibilities prior to providing the benefit is to thoroughly communicate the beneficiary's benefits.

  • Co-Payments -- The beneficiary has the right to be told in advance of the deductible and co-payments due under Medicare Part B. A provider who routinely waives Medicare co-payments or deductibles also could be held liable under the Medicare anti-kickback statute. This statute makes it illegal to offer, pay, solicit or receive anything of value as an inducement to generate business payable by Medicare. (Refer to section on "Co-payments and deductibles" below for more detail).
  • ABN — An Advance Beneficiary Notice (ABN) must be properly executed when indicated prior to providing the service.

Co-Payments and Deductibles

A provider who routinely waives Medicare co-payments or deductibles also could be held liable under the Medicare anti-kickback statute. This statute makes it illegal to offer, pay, solicit or receive anything of value as an inducement to generate business payable by Medicare. When providers forgive financial obligations for reasons other than genuine financial hardship of the particular patient, they may be unlawfully inducing that patient to purchase items or services from them.

One exception is made. Practitioners may forgive the co-payment in consideration of a particular patient's financial hardship. This hardship exception must not be used routinely but occasionally to address the special financial needs of a particular patient. Except in such special cases, a good faith effort to collect deductibles and co-payments must be made. Otherwise, claims submitted to Medicare may violate the relative statutes and other provisions of the law. This "good faith effort" is legal language permitting selective interpretation by the OIG. It may require an effort by the provider of soliciting documentation proving such hardship. It normally requires repeated attempts of billing and related collection behaviors by the provider. Evidence of the "good faith effort" must be available when the inspection team shows up. Without it, the provider is exposed to the full brunt of the law.

What are the penalties? Practitioners who submit a false claim to the Medicare program may be subject to criminal, civil or administrative liability for making false statements and/or submitting false claims to the Government. Penalties for this can include imprisonment, criminal fines, civil damages and forfeitures, civil monetary penalties and exclusion from Medicare and the State healthcare programs. In addition, any practitioner who routinely waives co-payments or deductibles can be criminally prosecuted and excluded from participating in Medicare and the State healthcare programs under the anti-kickback statute.

Finally, any practitioner who furnishes items or services to patients substantially in excess of the needs of such patients can be excluded from Medicare and the State healthcare programs.

The Office of Inspector General (OIG) has also identified marketing practices that may reveal this kind of evasive behavior:

  • Advertisements that state: "Medicare accepted as payment in full," "Insurance accepted as payment in full," or "No out-of-pocket expense." Advertisements that promise that "discounts" will be given to Medicare beneficiaries.

  • Routine use of "Financial Hardship" forms that state that the beneficiary is unable to pay the coinsurance/deductible while there is no "good faith" attempt to determine the beneficiary's actual financial condition.

  • Collection of co-payments and deductibles only where the beneficiary has Medicare supplemental insurance (the services are "free" to the beneficiary).

  • Charges to Medicare beneficiaries that are higher than those made to other persons for similar services and items (the higher charges offset the waiver of coinsurance).

  • Failure to collect co-payments or deductibles for a specific group of Medicare patients for reasons unrelated to indigence (waiving co-payments for all patients from a particular hospital in order to get referrals).

4. Referral Documentation Complete

Referrals
A referral may only be made by the treating physician when the beneficiary has been diagnosed with diabetes or non-dialysis kidney disease, supported by documentation maintained by the treating physician in the beneficiary's medical record. Referrals must be made for each episode of care and any reassessments prescribed during an episode of care as a result of a change in medical condition or diagnosis. The treating physician's UPIN number must appear on the HCFA-1500 claim form, or the electronic equivalent, submitted by a registered dietitian or nutrition professional.

Practice Tips:

  • ICD-9 codes, to the highest level of specificity must be provided by the treating physician, and must include diagnoses covered in the Medicare MNT benefit.
  • A signed copy of the treating physician's referral is required prior to providing MNT.
  • Changes in medical condition or diagnosis require receipt of a second printed referral from the treating physician. Consider use of an ABN for additional MNT provided beyond the episode of care for diabetes or non-dialysis kidney disease.
These four components of accepting a referral establish practitioners' access to the Medicare MNT benefit. Upon review of these components, dietetic professionals are now ready to begin to provide the Medicare MNT benefit. To provide the Medicare MNT benefit, dietetic professionals are required to use nationally established protocols/ guides for practice. ADA's MNT Evidence-Based Guides for Practice contain comprehensive sections that will assist all dietetic professionals to access and implement the Medicare MNT benefit.  Specifically, the Flowchart section in the ADA MNT Evidence-Based Guidesfor Practice can help dietetic professionals recognize pertinent clinical data to obtain from the referral source or client's medical record. The protocols can simplify RDs' data collection, a critical step in establishing access to the Medicare MNT benefit (see below). With this data in place, dietetic professionals can utilize the remaining sections of ADA's MNT Evidence-Based Guides for Practice to successfully provide the benefit.

I. Access the Benefit
  1. Verify eligibility
  2. MSP Screen/ Questionnaire
  3. Communicate benefits to beneficiary
  4. Access the treating physician referral and documentation

II. Implement the Benefit
    ADA Medical Nutrition Therapy Guides for Practice on CD-Rom
    CD-Rom Components:
    1. Overview
    2. Protocol Development and Review Panels
    3. Summary Page
    4. Flow Chart "prior to encounter 1 data collection"
    5. Encounter Process
    6. Nutrition Progress Notes
    7. Conclusion Statements and Worksheets
    8. Bibliography
    9. Appendices

To learn more or to purchase ADA's MNT Evidence-Based Guides for Practice, visit ADA's member-only web pages. Click to the online "Product Catalog" or visit main tool bar "Policy Initiatives & Advocacy" and then go to "MNT" or "Quality & Outcomes" located on the left-hand side bar.

MSP Screening Form Questionnaire Determination of Primary Insurance when Patient is Entitled to Medicare Part B

Medicare will be primary when a patient with Medicare Part B has no other insurance, has Medigap Supplemental insurance, has Medicaid in addition to Medicare, and/or is in one of the following situations:

Please place a checkmark next to the ONE statement of the following that is true for you:

____ 1) I am 65 or over, fully retired, and my spouse is also fully retired.Medicare is primary.
Date of Retirement _________ Date of Spouse's Retirement __________

____ 2) I am 65 or over, fully retired, and my spouse works for a company with LESS
than 20 employees. Medicare is primary for me.

____ 3) I am 65 or over, and work full time or part-time for a company with LESS
than 20 employees. Medicare is primary.

____ 4) I am under 65, am disabled, and I do not have primary coverage with a
Large Group Health Plan because I do not have nor does a family
member have "current employment status *." Medicare is primary for me.

____ 5) I am a Veteran entitled to Medicare, and I may choose either the VA or
Medicare to be responsible for payment of services covered by both programs.

____ A) If I choose Medicare, Medicare is primary for me. It is not necessary to
submit a claim to the VA for denial before sending to Medicare.

____B) If I choose the VA, Medicare is 2nd & all hospital services must be pre-
authorized by the VA.

Medicare will be Secondary Payor for a Patient with Medicare Part B when:

 ____ 1) I am 65 or over, fully retired, and my spouse works for a company with MORE than 20 employees. Medicare is second for me.

____ 2) I am 65 or over, and work full time or part-time for a company with MORE
than 20 employees. Medicare is second for me.

____ 3) I am under 65, am disabled, and I have primary coverage through a LGHP.
Medicare is second for me.

____ 4) I have End Stage Renal Disease. My Medicare coverage began _____
Medicare is second for me for the first 18 month or 30 month coordination period.

____ 5) I am entitled to Black Lung benefits. Medicare is second for me only for
treatment of lung conditions caused by mining.

____ 6) I was injured in an accident. __Auto __Work __Home __Other
Detailed billing information will be requested separately. Medicare is secondary for me.

* "Current Employment Status" means that an individual is actively working as an employee, the employer or is associated with the employer in a business relationship.

By completing this questionnaire and signing below, I acknowledge that my provider has made a good faith effort to determine whether any other insurance is primary to any Medicare coverage I may have.

 

Beneficiary's Signature ______________________________

 

Beneficiary's (PRINTED) Name______________________________

 

Date___________

 

Employee's Initials: ______________________________

 

Date___________  

*The information is for reference use only and does not constitute the rendering of legal, financial, or other professional advice of the American Dietetic Association. (07/04)

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