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Medicare was established by Congress to provide care to the elderly and disabled with significant medical conditions. Medicare does not cover some screening tests performed just to determine whether a condition is present or not. Medicare also does not cover services and procedures that are deemed "medically unnecessary". These services and procedures may still benefit you; however, due to limits in Medicare coverage you may need to pay for certain procedures that do not meet Medicare's criteria for medical necessity.
Medicare has strict criteria for determining whether a service or procedure qualifies for medical necessity and is a covered benefit. These criteria are periodically modified by local Medicare carriers (i.e., Adminastar) and our published on internet.(www.) Examples of a few procedures that have defined criteria of medical necessity include: eyelid surgery (blepharoplasty, blepharoptosis repair), skin lesion removal, Botox injections, some laboratory studies, and some imaging studies such as CT scans, MR imaging (MRI), MR angiography (MRA).
Unfortunately, Medicare makes the determination of medical necessity after a claim is submitted. Medicare does not have a mechanism to pre-approve your test or surgery. Dr. Klapper will try to help determine whether your planned medical or surgical service should meet criteria for medical necessity. For example, clinical measurements, photographs, and visual fields may be performed to help decide whether eyelid surgery would likely be a covered service. However, even if your referring doctor and Dr. Klapper feel that your eyelid surgery is interfering with your vision and should meet Medicare's medical necessity criteria, Medicare may still determine that your surgery was not "medically necessary". If Medicare does not pay for services you have received, then you will be financially responsible for your test or surgery.
If your doctor or medical facility believe that a test or procedure that is to be filed with Medicare may not be considered medically necessary by Medicare, then patients will be asked to sign an ABN. By signing this CMS approved form, you understand and agree that if Medicare denies your claim based on medical necessity then you are responsible for payment for that particular service. Separate ABNs may be necessary for surgeon fees, anesthesia fees, hospital charges, and laboratory expenses. Again, If Medicare does not pay for services you have received, then you will be financially responsible for your test or surgery.
Your doctor or hospital may bill you for services while Medicare is making its decision. If Medicare does pay for these particular services, you are entitled to a full refund (less any co-insurance amounts). If Medicare denies payment, you are personally and completely responsible for payment in full.
To participate in the Medicare program, Dr. Klapper must follow all of Medicare's rules and regulations, including the Advanced Beneficiary Notice. Hospitals and doctor's offices that provide free care to patients without first determining if there is financial need may place themselves at risk of violating governmental regulations about unfair business practices. If you refuse to sign the form, you are stating that you do not accept responsibility for payment. If Medicare were to deny your claim, then your doctor or hospital would not be able to bill you for the service, essentially offering the routine free care prohibited by Medicare.
Medicare does NOT pay for all of your health care costs. There are several exclusions from Medicare benefits. When you receive an item that is not a Medicare benefit, it is your responsibility to pay for it. Some eyelid and eyebrow surgery may be considered cosmetic surgery by Medicare. If your eyelid or eyebrow ptosis (droop) will not meet Medicare criteria for medical necessity, your surgery will be considered cosmetic. A claim will not be filed with Medicare for services that are not considered a covered Medicare benefit (i.e., cosmetic services). We will ask you to review and sign Medicare's NEMB and will provide you with an estimate of your costs that need to be paid prior to your cosmetic procedure(s). Please ask us if you do not understand why Medicare will not pay.
It is our sincere goal to help you better understand your Medicare coverage and potential financial responsibility. If you have any questions or concerns, either before your surgery or after you have received your Medicare Explanation of Benefits (EOB), please contact our office. Thank you for your understanding and for allowing us to participate in your care.
** This is NOT a legal document nor is it endorsed by the Centers for Medicare & Medicaid (CMS). The official Medicare Program provisions are contained in relevant laws, regulations, and rulings available directly from the CMS [http://www.medicare.gov].
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Contact our office to discuss your eyelid problem with Dr. Klapper or a member of his staff. (317) 818-1000
