Even if you feel comfortable with all things Medicare, chances are there’s a new rule in the works (oh, looky here) that could trip you up. Yes, the rules are always changing—and even the ones that have been in place for a while could get you stuck in a pickle (mmm, pickles). That’s especially true with the rules around providing treatment on a cash-pay basis, because your restrictions and obligations vary based on your relationship with Medicare—if you have one at all. Why, you ask? Let’s dive in.

Down with Denials! 5 Claim Fixes to Make Sure Your PT Clinic Gets Paid - Regular BannerDown with Denials! 5 Claim Fixes to Make Sure Your PT Clinic Gets Paid - Small Banner

Covered, Cash-Based Services

CMS has strict rules governing the manner in which providers can—and cannot—collect payment from Medicare beneficiaries. Those rules are especially tricky for therapists looking to provide services on a cash-pay basis—and they can change based on your relationship with Medicare. To that end, there are three types of relationships PTs can have with Medicare:

  1. Participating providers cannot accept payment directly from a beneficiary for any Medicare-covered services (beyond the standard deductible and 20% coinsurance, that is).
  2. Non-participating providers can accept payment from the beneficiary at the time of service. However, you must still submit a claim to Medicare for covered services so that Medicare can reimburse the patient directly.
  3. Providers who have no relationship with Medicare cannot provide covered services to a Medicare beneficiary on a private-pay basis—unless the patient (or his or her legal representative) of his or her own free will requests that you do not send claims or protected health information to Medicare.

Non-Covered Services

Now, Medicare doesn’t always cover all rehab therapy services—and therapists may accept cash from Medicare beneficiaries (beyond their deductibles, coinsurances, and copayments) for those services that Medicare doesn’t cover. In other words, you can accept cash if your services fall into one of these two categories:

  1. The Statutory Scenario: A service falls into this category if it’s considered preventive or wellness- or fitness-related. Now, under the Affordable Care Act, Medicare will cover some wellness and prevention services. But, it’s important to understand that for these services to be covered, they must be delivered during once-annual visits to the patient’s primary physician. So, unless you’re working as a member of a physician’s established wellness program, it’s unlikely that your wellness services will overlap with what Medicare covers.
  2. The Medical Necessity Scenario: A service falls into this category if it’s not considered “reasonable and (medically) necessary.” For more information on medical necessity, check out Section 220.2 of the Medicare Benefit Policy Manual, or take a look at this blog post.

Determining whether—and when—you can offer cash-based services to Medicare beneficiaries comes down to your relationship with Medicare and the medical necessity of the services you’re providing. In some cases, those factors could prevent you from telling your patients to show you the money. Also, keep in mind that before you’re able to provide services to a Medicare patient on a self-pay basis, you must issue what’s called an Advance Beneficiary Notice of Noncoverage (ABN). Stumped on how ABNs fit into the cash-pay model? Swing by the WebPT Blog tomorrow as we dive deeper into this topic and crack another Medicare misconception.

Looking to decode another Medicare regulation that’s got you stumped? Check out our latest webinar to learn about the nine most common Medicare misconceptions impacting PTs, OTs, and SLPs.

What questions do you still have about Medicare’s rules around cash-pay? Has your practice ever thought about changing its relationship with Medicare? Tell us in the comment section below.

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • Why Issuing Blanket ABNs is a No-No Image

    articleOct 28, 2016 | 4 min. read

    Why Issuing Blanket ABNs is a No-No

    With Medicare routinely changing and tightening its rules on reimbursement, PTs may be worried about receiving payment in a timely, efficient manner. Fortunately, Advance Beneficiary Notices of Noncoverage (ABNs) help you cover all your financial bases, as they: put the onus on your Medicare patients to decide whether they would like to accept financial liability (i.e., pay out-of-pocket) for the therapy services you provide; and safeguard you when Medicare denies a claim. So, why not issue ABNs …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • The PT's Guide to Billing Image

    downloadJun 7, 2016

    The PT's Guide to Billing

    When it comes to physical therapy billing, you have to know your stuff—because even the simplest mistakes can cause denials. Of course, knowing billing backwards and forwards doesn’t have to be complicated. That’s why we created a comprehensive billing resource specifically for PTs. Take the guesswork out of billing. Enter your email address below, and we’ll send your free guide.

  • Maintenance, Medicare, and Medical Necessity: Unpacking the Jimmo Update Image

    articleOct 5, 2017 | 5 min. read

    Maintenance, Medicare, and Medical Necessity: Unpacking the Jimmo Update

    Hey, have you heard the good news? CMS has completed all required action items laid out in the Jimmo v. Sebelius settlement. If you’re scratching your head and wondering why that matters, here’s the rundown: a few years ago, a group of Medicare providers alleged that CMS contractors made determinations on claims for skilled care based on an inappropriate “Improvement Standard.” These providers took CMS to court, and the court determined that CMS needed to clarify and …

  • The PT’s Guide to Surviving a Medicare Audit Image

    articleMay 30, 2016 | 5 min. read

    The PT’s Guide to Surviving a Medicare Audit

    “How can I avoid being audited by Medicare?” This is one of the compliance questions I hear most frequently, and the honest answer is, quite simply, that you can’t. Just because CMS or one of its auditing entities hasn’t come knocking on your door doesn’t mean you’re not being audited. In fact, every claim you submit undergoes statistical analysis, and Medicare compares your claims data to the data for all other claims submitted. Furthermore, Medicare now analyzes …

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.