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HCFA regulation addresses medical necessity of diagnostic testing
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WASHINGTON — In an effort to weed out Medicare reimbursements for medically unnecessary diagnostic tests, the Health Care Financing Administration (HCFA) has a new regulation on the books that optometrists fear may leave them out of the loop.
Printed in the Nov. 22, 1996, Federal Register (page 59554, paragraph 410.32), the three-paragraph policy falls under supplementary medical insurance benefits. The policy reads, in part, that diagnostic tests "must be ordered by the physician who treats the beneficiary, that is, the physician who is actively furnishing a consultation or treating a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem."
T. Joel Byars, OD, president of the American Optometric Association (AOA), said the AOA has a problem with the language.
"In an HMO situation, the primary care physician is considered to be the case manager," he said. "You could interpret this ruling as the case manager being the only person permitted to order any diagnostic tests," therefore, potentially excluding legitimate diagnostic tests performed by optometrists.
ODs, MDs expressed concerns
Prior to publication, the AOA had expressed serious concerns over the proposed wording.
"It could be construed to preclude some of the primary care providers from conducting certain diagnostic tests for proper diagnosis, even though treatment might be performed by another provider," said Dr. Byars. "We made a presentation to HCFA and provided them with some additional information. HCFA said it is their intent to assume that the physician who ordered the tests would be responsible for the management of some aspects of the patient's care and, therefore, did not feel the need to change any wording."
Dr. Byars noted, however, HFCA understands that there might be some problems with interpretation. "At the present time, we hope — and to some degree believe — that HCFA will readdress this issue," Dr. Byars said. "We'll watch it closely and hope that it does not prevent optometrists from using diagnostic codes."
Dr. Byars said the AOA would like the regulation to be spelled out more precisely, so "that if a primary care provider — or even a specialist — receives a referral and has to perform additional tests, he or she has the right to order additional tests that are in the patient's best interest."
Must prove medical necessity
"We're trying to state a Medicare policy in regulations. [The policy has] never been stated before," said a spokesperson for HCFA, who requested anonymity. "We always thought [the policy] was implicit. Obviously, though, there is a tendency to abuse it."
The new regulation will also serve as an official reference for hearing officers and others reviewing Medicare claims.
"The only tests we will pay for are those that are ordered by someone who has some relationship to that patient," said the HCFA spokesperson. "There have been problems with physicians and others ordering tests for Medicare beneficiaries who have no relationship whatsoever to that beneficiary. They are simply ordering the tests. They haven't seen the patient, they don't know who the patient is. All they are doing is signing orders for tests. This is an announcement of Medicare policy in terms of medical necessity."
As for being a cost-containment measure, "If we assume that all tests ordered are medically necessary, we wouldn't save a nickel," said the spokesperson.
Dr. Byars said the AOA has no problem with the ruling, "as long as a provider who is managing one particular part of patient care can still order diagnostic tests."
AOA members are encouraged to carefully monitor their carrier and report to the AOA any problems they encounter when using diagnostic codes.
The American Academy of Ophthalmology declined comment on the new policy.
For Your Information:
- T. Joel Byars, OD, is president of the American Optometric Association. He can be reached at Box 37, Morrow, GA 30260; (770) 961-4967; fax: (770) 961-1086.