Medicare Preventive Services and Health Care Reform

Last week the Obama administration announced which “preventive” services are to have no co-payments or deductibles applied under the recent health care reform legislation. You should note that this announcement does NOT apply to Medicare, but only to new insurance plans which are effective beginning in September.

Nonetheless, it gives us a good indication of exactly which services in Medicare will be wholly paid for by the Medicare program beginning next year, 2011. As you know, preventive services in Medicare currently have a hodgepodge of payment rules: some have neither any coinsurance nor a deductible, some have deductibles but no coinsurance, some have coinsurance and no deductibles, and some have both. (The details are in Chapter 4 of the book.) So what is good is first, that this hodgepodge will be simplified, and, second, that you will be incentivized to keep up with your preventive services as you won’t have to pay anything out-of-pocket for them. And as far as I can tell with the new law, this will be true whether you are in Original Medicare or in Medicare Advantage (Part C). The details on all this will be coming out in the fall as Medicare publishes the official regulations on preventive services.

And did you note that I used parentheses around “preventive” services? This is because some of the services so classified are, in my judgment, more “intervention” services than merely preventive ones. For example, the recently issued rules mandate “free” tobacco cessation services, that is, active counseling to get you to stop smoking, chewing or snuffing, and we can expect Medicare will do the same. So “stay tuned” to see exactly what Medicare will and won’t define as “preventive” services.

"Enrolled" Physicians and Practitioners and DMEPOS

Beginning this year, note that only certain kinds of physicians and non-physician practitioners can order or refer a Medicare beneficiary for durable medical equipment (DME), prosthetics, orthotics, and supplies. (Sometimes the acronym DMEPOS is used to describe all these items). These kinds include:

Physicians (doctors of medicine or osteopathy—all specialties,
and doctors of dental medicine, dental surgery, podiatric medicine, optometry, and chiropractic medicine),
Physician Assistants,
Certified Clinical Nurse Specialists,
Nurse Practitioners,
Clinical Psychologists,
Certified Nurse Midwives, and
Clinical Social Workers.

In addition, each ordering / referring practitioner must be currently enrolled as a Medicare approved physician or practitioner. For example, a Department of Veterans Affairs’ doctor can order DME for a veteran that for some reason the VA will not pay for, but that physician must be enrolled in the Medicare system even though they would have no occasion to submit a claim to Medicare.

It is inappropriate for a DMEPOS supplier to use the Advance Beneficiary Notice of Noncoverage (ABN) if a claim is rejected because the ordering / referring physician or practitioner is not enrolled in Medicare. An ABN is appropriate only when a supplier expects Medicare to deny coverage for an item or service under the Limitation on Liability provisions of Section 1879 of the Social Security Act.

Medicare made this change to tighten up on who can OK DMEPOS, as these items have been beset by fraud and abuse.