Medicare to ease covered procedure guessing game

Prior determination would allow doctors and patients to determine their financial risks aheads of time for certain surgeries.

By David Glendinning, AMNews staff. Sept. 19, 2005.

Washington -- When a patient is in line for an expensive procedure that Medicare might not cover, the treating physician now can either warn the beneficiary that the government might not pay for it or take a chance and file a claim after administering the treatment. But soon the government will offer a third option.

Under a recently proposed federal rule, Medicare carriers will be required to list on their Web sites the 50 costliest services that the program might cover, as well as any plastic and dental surgeries that average at least $1,000 and have the potential for reimbursement.

If they get the say-so from patients contemplating these procedures, physicians could demand binding advance statements from the carriers as to whether they will pay for the services.

Such prior determinations could affect some patients' decisions about whether to proceed with the expensive surgeries that their doctors recommend. Patients who have nailed down a guarantee of federal payment will be more likely to go ahead with the procedure than beneficiaries whose funding source is in doubt, federal officials said.

Physicians and patients currently cannot receive prior determinations from Medicare. Doctors can minimize only their own financial risk by issuing advance beneficiary notices, or ABNs, that explain the possibility that the government will deny the claims. The notices also inform patients that they would be on their own when it comes to paying the bill.