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UNDERSTANDING AND OVERCOMING WAIVER OF LIABILITY

BILATERAL SURGERY

DEVELOPMENT LETTER FOR MEDICARE AS SECODARY PAYOR



In this weeks issue we address more topics which are critical to 
obtaining

maximum and timely reimbursement for a healthcare provider. In 
this

newsletter we provide information on protecting the provider from 
being held

financially liable under waiver of liability, obtaining proper 
maximized

reimbursement for bilateral surgeries, and preventing delays in 
Medicare as

Secondary Payor reimbursements. We are still looking for 
contributions from

credentialed experts in healthcare reimbursement related fields. 
Please let

us know your ideas by email - sales@accuchecker.com



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UNDERSTANDING AND OVERCOMING WAIVER OF LIABILITY



Medicare may deny claims that it deems not medically reasonable 
or

necessary. In such a circumstance the patient may be protected 
from having

to pay for such services under the "waiver of liability" doctrine. 
The

government is protected under Section 1862(a)(1) of the social 
security act,

which prohibits payment for services that are not deemed 
medically

reasonable or necessary.



The following are some of the reasons a service may be considered 
not

reasonable and necessary:



* The Service is not covered considering the diagnosis/condition of 
the

patient.

* The frequency or range of the procedure was beyond the accepted 
standards

of medical practice.

* The medical documentation did not justify the medical necessity 
of the

service.



Providers are expected to be aware of what conditions may lead to 
a

rejection or reduction of benefits, especially when:



* The medical necessity requirements were published by Medicare 
Part B

* The provider has received a previous review, waiver of liability, 
hearing

decision, or other notice, which informed the provider of the 
medical

necessity requirements.

* A denial or reduction of payment on the same or similar service 
has been

received.



However, there is protection for the provider as well:



* If the provider notifies the patient in advance that payment for 
the

service may be denied or reduced, the provider is not held 
financially

liable for the service.



The following is a standard letter, which can be used to explain 
"waiver of

liability" to the patient and indemnify the provider against being 
held

financially liable for the service.



Waiver Liability (WL) & Advanced Beneficiary Notice (ABN) 
Agreement

____________________________________________________
__________



One or more of the procedures or CPT4 codes listed below are 
requested by

the physician, either separately or as part of a panel, profile or 
other

group test group, for

this patient with Medicare coverage AND the patient's diagnosis 
DOES NOT

match

any of the ICD-9 codes established as eligible for coverage by the 
local or

regional Medicare carrier.



Medicare will only pay for services that it determines to be 
'reasonable and

necessary' under section 1862(a)(1) of the Medicare law.  If 
Medicare

determines

that a particular service, although would otherwise be covered, is 
not

'reasonable

and necessary' under Medicare program standards, Medicare will 
deny payment

for

that service.  I believe that in your care, Medicare is likely to deny

payment for the following service(s):



	Procedure:			CPT4:















For the following REASON:



______Medicare usually does not pay for the service for the 
provided

diagnosis.



______Medicare does not pay for tests that do not have FDA 
approval.



______Medicare usually does not pay for routine exam/lab work



______Other:__________________________________________
__________





I have been notified by my physician/supplier that he/she believes 
that, in

my case, Medicare is likely to deny payment for the services 
identified

above for the reasons noted.  If Medicare denies payment, I AGREE 
to be

personally and fully responsible for payment.







____________________________________
	_____________________________

Beneficiary's Signature	Date





____________________________________
	_____________________________

Beneficiary's Name (PLEASE PRINT)		Beneficiary's 
Insurance #



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----------------

--------------------------------



I have been informed by my provider that he/she believes, in my 
case,

Medicare under section 1862(a)(1) is likely to deny payment for the 
test(s)

identified above, for the reason stated.  I understand that I have 
the right

to decide whether or not to have the identified procedure(s) 
performed.  I

have decided NOT to have the identified procedure(s) performed 
because I am

not willing to be personally responsible for payment.







_____________________________________	    
_____________________________

Beneficiary's Signature	Date

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