Understanding Non-Covered Services In Medical Billing

Most medical services and treatments provided by physicians, clinics, and hospitals are often covered by health insurance companies, public health institutions, and other payer groups. Most prescription medications, wellness care, and even patient-use medical equipment fall under this category. However, many medical billing firms are aware that private payers and government agencies do not always cover specific treatments, goods, medications, and services. These are called non-covered services which require the patient to pay out of their pocket. If you are confused, here is a guide to understanding non-covered services in medical billing!

What are Non-Covered Medical Services

Like its name, non-covered medical services are services that are not covered by the government or private payers. There are many medical services offered by medical providers but there are some non-covered medical services you should be aware of. This includes, but is not limited to:

  • Treatments and supplies that are medically unjustified or unneeded
  • Items or services that are not covered as part of the patient’s treatment plan
  • Services and supplies that are not covered by another service’s basic allowance
  • Excessive diagnostic procedures and therapeutic treatment
  • Unrelated screening exams and tests
  • Therapies irrelevant to the patient’s symptoms

To be recognized as a claim, the services should meet the particular medical requirements as stated in the statute, manuals, and regulations outlined by the National Coverage Determinations and Local Coverage Determinations. If they do meet these requirements, the attending physician must specify the exact symptom, sign, or patient complaint that makes the service necessary and reasonable.

How Can a Service be Deemed Medically Necessary and Reasonable

To qualify as medically necessary and reasonable, the items and services must be proven effective and safe. The following criteria are used in this process:

  • Symptoms or diagnoses are consistent with the sickness or injury
  • With universally acknowledged professional medical standards, it is regarded as “Necessary and Consistent.”
  • It is neither exploratory nor experimental
  • Not offered primarily for the patient, attending physician, specialist or other physicians, or third-party medical vendor’s convenience
  • The procedures are offered at an acceptable and applicable level so that the patient can receive them safely and efficiently

How to Collect Payment for Non-Covered Services

Usually, a physician or other medical professional can bill the patient for non-covered services. Before performing the diagnosis, treatment, or service, the physician should inform the patient so that they are aware that they are liable for the payment as an out-of-pocket charge. You can also check the payer’s website for coverage information on that particular service.

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