Our healthcare and business law firm advises many physicians and medical practices on Medicare compliance, including one of the most foundational questions a Medicare-participating provider must answer before offering a new service: is this a covered service? The answer has significant legal and financial consequences. This post walks through a framework for analyzing whether a service is covered under Medicare, why that distinction matters, and what options a provider has when a service may or may not be covered. If you would like to discuss Medicare compliance for your practice or would like to discuss this blog post, you may contact our healthcare and business law firm at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@littlehealthlaw.com. You may also learn more about our law firm by visiting www.littlehealthlaw.com.
(1) Why the Covered vs. Non-Covered Distinction Matters
As a Medicare-participating provider, you have agreed—through your provider agreement—to accept Medicare’s approved payment amount as payment in full for covered services. That means if a service is covered by Medicare, you generally cannot bill the patient a separate or higher fee for that same service. Doing so can result in severe penalties, including civil monetary penalties and exclusion from the Medicare program.
On the other hand, if a service is never a covered service, you are not bound by Medicare’s billing rates, are not required to submit a claim to Medicare, and can Continue reading ›
