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.
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.
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.
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.