Carriers have been advised by HCFA not to reject a claim simply because the waiver is attached. Along with the advance beneficiary notice, a cover letter to beneficiaries explaining why they are being asked to sign a form might be useful. Such a letter might explain that Medicare and providers do not always agree on what constitutes quality care, possibly because expenditure reduction is a priority for the federal government while quality of care is your top priority. Medicare does not hold the beneficiaries financially accountable for the professional judgment of their providers, therefore the providers are financially responsible for the reasonableness and necessity of the services they provide. Psychologists who provide psychological testing may find that their claims are reduced rather than denied outright.
Carriers reduce the number of hours in the claim and pay a lesser amount.
This reduction is usually based on whether or not the carrier deems the additional hours to be reasonable and necessary. There are certain situations where Medicare coverage of particular services is less definitive resulting in questions regarding what a provider can charge the beneficiary for such services. However, coverage in this case is based on carrier discretion and thus the provider cannot be certain whether the service will be paid until the carrier makes its coverage determination. The ABN should be designed to clearly indicate the intent of the provider and thus may protect the provider if a claim is questioned by either the carrier or the beneficiary. There are some situations where a service would be covered by Medicare, however the beneficiary, for reasons of his or her own, declines to authorize the psychologist to submit a claim or to furnish confidential medical information to Medicare that is needed to submit a proper claim.