For patients and physicians, obtaining health care in the United States sometimes feels like gambling with payors. That uncertain feeling arises from ambiguous coverage guidelines that tilt in the payor’s favor and the suspicion that a claim will not be adequately paid or maybe not paid at all. For many procedures, especially those that are relatively new or infrequently performed, there are no published coverage policies, leaving physicians and facilities to question whether to provide the service.
To derisk this situation, the financial responsibility for a noncovered service or unpaid claim belongs to the beneficiary or patient. That requires counseling the patient prior to the procedure. In the case where several different glaucoma surgical procedures are being considered, the following guidance may help structure that conversation.
- Begin by emphasizing that glaucoma surgery is ultimately the patient’s choice, even when you recommend it. Explain that glaucoma can be managed in several ways—laser procedures, medications, intracameral drug-eluting implants, aqueous drainage devices, or tube shunts—and that together you determine the best option after reviewing the alternatives. Reimbursement is one of the factors that must be considered.
- Clarify that the procedure you recommend may not be covered by the patient’s insurance. As a result, the patient may have to decide between the recommended option and a covered alternative. Help the patient understand the clinical differences: potential intraocular pressure (IOP) reduction, recovery expectations, duration of effect, and the likelihood of requiring additional medication. Explain that expected outcomes are generally more favorable with the recommended procedure.
- Discuss your experience with the patient’s insurance plan and note that reimbursement for this procedure has been inconsistent. Make clear that if the insurer denies coverage, the patient will be financially responsible for the cost of the procedure. By contrast, choosing a covered surgery limits the patient’s cost to deductibles and copayments.
- Review the planned surgery (right eye, left eye, or both) and outline the anticipated fees, including the surgeon’s charge for one or both eyes and any additional facility or anesthesia costs. Assure the patient that your office will submit a claim on their behalf. If the claim is paid, the patient will receive a refund minus applicable deductibles or copayments.
- Conclude by confirming that the patient understands the clinical and financial implications and asking whether they would like to proceed.
After fully informing the patient of their choices and obtaining consent to proceed with the procedure, it is crucial to document the patient’s acceptance of financial responsibility and agreement to pay for it. There are several ways to do that, depending on the patient’s health insurance plan.
- For traditional Medicare (Part B), use the Advance Beneficiary Notice of Noncoverage (ABN) form approved by the federal Office of Management and Budget. (Note: the current form is due to expire January 31, 2026.)
- For Medicare Advantage (Part C), obtain predetermination of benefits. Medicare Advantage Organizations (MAOs) may not use the CMS-R-131 ABN form.
- For Non-Medicare, use a Notice of Exclusion from Health Plan Benefits.
For Medicare beneficiaries, §1879 of the Social Security Act limits their liability for a denied or noncovered service, even if payment has already been made. The beneficiary is not financially responsible, and the provider cannot seek payment from them, if the beneficiary “did not know, and could not reasonably have been expected to know, that payment would not be made…” Without proof that the beneficiary accepted financial responsibility in advance, you will be required to refund any payment collected and will not be permitted to bill the patient.
Similar limitations of liability apply to Medicare Advantage (MA) plans. Because MA plans sometimes offer more extensive coverage, physicians may be surprised to learn that some items and services are treated differently than under traditional Medicare. For example, a refraction may be a covered service in some MA plans. In addition, CMS grants MAOs considerable latitude in determining coverage and payment, so long as benefits are not less generous than the statutory benefits under Medicare Parts A and B. In practice, when no formal Part B local coverage determination exists, an MAO may deny coverage for an item or service. This is common for newer procedures, particularly those reported with Category III or unlisted CPT codes. Notably, a prior authorization from an MA plan does not guarantee coverage or payment, making predetermination of benefits especially useful.
Importantly, the payor makes the determination about coverage, not the physician, so a claim should be filed unless you have clear instructions to the contrary from the beneficiary or the payor. Even if you don’t file a claim based on your assumption that an item or service is not covered, the beneficiary might file a claim using a CMS-1490S form without your knowledge or cooperation.
When submitting claims for reimbursement, modifiers can provide additional information. Use modifier GA to indicate that you are uncertain about coverage, have informed the beneficiary using an ABN or similar document, and probably the claim will be denied but you want an official determination. Use modifier GY to indicate that the item or service is not covered by statute or formal payor policy and you want an official denial. The response from the payor may be useful when the beneficiary has secondary insurance that might cover the denied item or service. GP
