Medicare Mandatory Enrollment and Claim Submission Requirements

A Primer for Audiologists and Speech-Language Pathologists Providing Outpatient Services

Audiologists and speech-language pathologists (SLPs) who provide outpatient services to Medicare beneficiaries need to comply with Medicare’s mandatory enrollment and claims submission requirements. This resource provides information and key considerations on Medicare requirements related to the mandatory enrollment and claims submission, including setting fees, how to enroll, and supervising students, as well as specific considerations for university clinics.

On this page:

Know the Medicare Enrollment Requirements

    If you are an audiologist or SLP who provides outpatient services to patients who qualify for Medicare—by virtue of age or disability—under Part B of the Medicare program and you work in a university clinic, office, or private practice setting, federal law requires you to enroll in and bill the Medicare program for covered services provided to Medicare beneficiaries. This means you will need to get a National Provider Identifier (NPI) number and complete the Medicare enrollment application(s). Once enrolled as a Medicare provider, you must submit claims to Medicare and can only collect applicable co-payments and deductibles from Medicare beneficiaries for covered services.

    There are some limited circumstances where a clinician may not have to enroll and submit claims themselves:

    • Clinicians who work in facility-based settings, such as skilled nursing facilities, do not need to independently enroll and bill their services to Medicare because their services are billed through the facility.

    • SLPs may also bill “incident to” a physician when working under the physician’s direct supervision in an office or clinic setting.

    Audiologists are not allowed to bill their services “incident to” a physician.

    ASHA's website provides detailed information on coverage and payment for audiology and speech-language pathology services across settings.

    Set Your Rates

    Accepting Cash From Medicare Beneficiaries

    Choosing not to enroll in and bill Medicare for covered services provided to Medicare beneficiaries and billing the patient directly instead is often referred to as “opting out.” Under federal law, only certain categories of providers (e.g., physicians) are allowed to opt out. Audiologists and SLPs are not included on the list of clinicians who are allowed to opt out, so they are required to enroll in and bill Medicare under most circumstances.

    Even if a Medicare beneficiary is willing to pay you cash, you are not allowed to accept payment from them—with the exception of applicable co-payments and deductibles. However, there are some circumstances when it may be appropriate to accept payment directly from the Medicare beneficiary:

    • When services are excluded from coverage by law. You can bill the patient for services that are not covered when they are excluded by law. For example, under law, hearing aids are not covered by Medicare. So the patient can be billed directly for hearing aids.

    • When services are excluded from coverage because they don’t require the skills of a clinician. Billable services must be considered skilled services, which require the clinical experience and judgment of the clinician. If the services could be performed by the patient or by a family member, these services are considered unskilled and thus not billable to Medicare (and likely many private insurers). It is unlikely that audiologists or SLPs are providing unskilled services to their patients.

    • When services aren’t considered medically necessary. Medically necessary services are defined by Medicare as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Services could improve or maintain function for the patient. If services don’t meet the medical necessity criteria, even when performed by a clinician, they are not billable to Medicare. However, clinicians should consider discharge criteria, including when services no longer result in measurable benefit, before charging patients out of pocket for services that aren’t considered medically necessary.

    Providing Free Services to Medicare Beneficiaries

    You can provide free services only if you have a policy in writing that applies to all of your patients—regardless of payer. If you have such a policy, then you could provide free services to Medicare beneficiaries and would not need to enroll in Medicare. For example, you could have a policy that you will provide free services to any patients who have an income below a certain dollar amount and then apply that to all your patients regardless of payer. You should consult an attorney to ensure that your free services policy complies with applicable state and federal laws.

    Offering Reduced Costs for Services or Charging a Flat Rate

    To offer services at a reduced cost or to charge a flat rate (e.g., $20 per session/hour), you should establish a fee schedule rate for your services that considers a value for each of the Current Procedural Terminology (CPT®) codes you will bill to insurers, including Medicare. Factors clinicians often consider when developing fee schedule rates include (a) the cost of doing business (e.g., rent, utilities, supplies, salaries); (b) the ability to make a profit; and/or (c) charitable mission. These rates should apply to all of your patients regardless of payer.

    Medicare will pay a clinician the Medicare-allowed rate or the clinician’s rate, whichever is less. If your practice, office, or university clinic has determined that providing reduced-cost services to members of the community is core to its mission, you can establish fee schedule rates lower than the Medicare rate. This means that your reimbursement from Medicare will be lower.

    Enrolling in and billing Medicare could be seen as an opportunity to secure a new or additional source of revenue. Perhaps these funds could be used to offset clinic operating expenses, hire more clinicians, and/or expand services to additional patient populations

    For additional information on billing and coding, see the following helpful ASHA resources:

    ASHA tracks the reimbursement for audiology and speech-language pathology services and updates this information annually.

    Comply With Medicare Requirements

    Avoiding Medicare Requirements

    If you have not implemented Medicare requirements (e.g., Medicare documentation, student supervision) and you are working with Medicare beneficiaries, then you are not in compliance with federal law. Failure to comply with Medicare requirements does not mean that you can “avoid” enrolling in and billing Medicare for your services.

    For example, Medicare requires personal supervision of student services in outpatient settings, meaning the licensed audiologist or SLP is in the room with the patient and student as the services are delivered. The student can participate in service delivery, but the licensed clinician should be fully engaged and guiding and directing the service delivery, and the clinician maintains liability for the services provided and associated outcomes. The licensed audiologist or SLP could not state the service is not covered because it was provided by a student without the appropriate level of supervision. Medicare would expect the licensed clinician to enroll in and bill Medicare for the covered service and follow all applicable coverage requirements (e.g., student supervision requirements).  

    Supervision Requirements for Students

    Under Part B, students require direct personal supervision, which means that the audiologist or SLP must be in the room and guiding the activities. Learn more from these ASHA resources:

    Myths About Medicare Coverage Exclusions

    There may be some confusion or misinformation regarding Medicare coverage of services that exceed a particular dollar amount or that may fall under the category of “maintenance therapy.”

    Congress permanently repealed the therapy cap in 2018 and replaced it with two financial thresholds that require administrative adjustments to claims (e.g., application of a modifier). Therefore, Medicare beneficiaries can continue to receive medically necessary treatment with no arbitrary payment limitations. The threshold that triggers potential medical review is $3,000 for speech-language pathology and physical therapy combined.

    There is also a “KX” modifier threshold, at which point clinicians must report the “KX” modifier on the claim to demonstrate continued medical need for services. The KX modifier threshold increases annually. There is one threshold for physical therapy and speech-language pathology services combined. ASHA’s website provides more information regarding the permanent repeal of the cap and the targeted manual medical review process.

    With regard to “maintenance therapy,” a lawsuit was settled in 2013 and subsequently re-affirmed between the U.S. Department of Health and Human Services―which oversees the Centers for Medicare & Medicaid Services (CMS)―and the Center for Medicare Advocacy, an organization that advocates on behalf of Medicare beneficiaries. Under the terms of the settlement, if therapy is being provided to maintain a level of function or to prevent further deterioration, these services may be covered under Medicare. This is critically important to patients with conditions for which therapy may prevent deterioration for a period of time, such as Parkinson’s disease. SLPs can also be paid to develop a maintenance program in which they train the Medicare beneficiary, or a caregiver, to perform certain activities.

    Getting Everyone Enrolled

    In order to bill Medicare, every provider (i.e., audiologist or SLP) in university clinics and private practice settings is required to be independently enrolled because Medicare expects the NPI of the rendering provider (the clinician who delivered the services to the beneficiary) to appear on the claim. There is a provision that allows physicians—and a few other select groups of clinicians—to bill for the services delivered by another physician under the original physician’s NPI. This arrangement, known as locum tenens, is used when a physician is sick, goes on vacation, is on family leave, or is involved in other exceptional or atypical circumstances. However, audiologists and SLPs are not on the list of provider types who can use locum tenens, which is limited by law, and cannot bill for another provider’s services under their own NPI. For example, if a clinic director was the only SLP enrolled in Medicare and all the services of the other SLPs in the clinic were billed under the clinic director’s NPI, it would raise an audit red flag. An auditor would wonder how one person could deliver so many services in a given day.

    Billing Incident-To

    SLPs may bill “incident to” a physician without enrolling if they work under the direct supervision of that physician. However, audiologists are statutorily prohibited from billing “incident to.” For more information, see ASHA’s resources on “incident to” billing for audiologists and SLPs.

    Note: Learn more about the NPI, including how to get one.

    Using the Advanced Beneficiary Notice (ABN)

    An ABN is a voluntary form that the provider and beneficiary complete to ensure that the beneficiary is aware of a potential financial obligation to the provider if Medicare does not cover a service. CMS expects providers and beneficiaries to rarely use this form. As a result, an ABN could not be used in an instance where an audiologist or SLP does not want to enroll in and bill Medicare in order to collect cash from the beneficiary. If an ABN is used routinely, it would raise an audit red flag because a modifier must be put on the claim indicating that an ABN is on file in the patient’s medical record.

    An example of an appropriate use of an ABN would be when a patient needs a hearing aid, which is not covered by Medicare but is covered by the patient’s secondary insurance. The secondary insurance may need the denial from Medicare to trigger coverage. If you are submitting a claim to Medicare, you must indicate the use of the ABN on the claim form with a modifier.

    Note: Learn more about using an ABN for audiologists. 

    Billing Medicare as a Nonparticipating Provider

    Regardless of whether you elect to be a participating or nonparticipating provider under Medicare, you are still required to enroll in Medicare and submit a claim. Being a nonparticipating provider is still a form of Medicare enrollment, though many clinicians mistakenly believe it means you are electing to opt out of Medicare (see above for information associated with opting out of Medicare). All Medicare coverage rules, such as documentation and student supervision requirements, are applicable to participating and nonparticipating clinicians alike.

    ASHA recommends that audiologists and SLPs who enroll in Medicare elect to be participating providers because it is less administratively complex than enrolling as a nonparticipating provider. Nonparticipating providers can collect cash from the beneficiary, and the beneficiary can then submit the claim for reimbursement. There is also an opportunity to achieve a slightly higher co-payment (known as the limiting charge) from the beneficiary. However, given that many Medicare beneficiaries are on a fixed income, collecting this extra money can be challenging.

    Ultimately, each individual clinician needs to decide whether to be a participating or nonparticipating provider based on their business model and needs.

    Electing Not to Treat Medicare Beneficiaries

    If you determine that your university clinic or private practice is unable or unwilling to enroll in and bill Medicare, then you can tell Medicare beneficiaries that you do not accept Medicare. However, that means that you will not be able to treat Medicare beneficiaries.

    Realizing That Your University Clinic/Private Practice Is Not in Compliance With Medicare Requirements

    Medicare billing requirements for SLPs went into effect in 2009 but are long-standing for audiologists. If you believe that your university clinic or private practice is not in compliance, you will need to consult legal counsel to determine how best to proceed.

    Follow the Steps for Medicare Enrollment

    There are three steps required to enroll in Medicare:

    Step 1. Obtain an NPI number

    Each clinician in the private practice or university clinic will need to obtain an individual NPI number. The clinic itself will also likely need its own NPI number.

    CMS offers more information on the NPI, including a general overview and how to apply. During the application process, you will need the following:

    • Taxonomy code for SLPs: 235Z00000X
      Provider type: 23
    • Taxonomy code for audiologists: 231H00000X
      Provider type: 34

    Note: Obtaining an NPI is not considered an automatic enrollment into the Medicare program. Learn more at ASHA's NPI resource page.

    Step 2. Fill out the enrollment application

    Each clinician will need to fill out the 855I [PDF] (I for “individual”) enrollment application. The clinic will need to complete the 855B [PDF] (B for “business”) enrollment application. Then each clinician may choose to reassign their Medicare payments to the clinic using the 855-R [PDF] (R for “reassignment”) application form.

    We highly recommend that the application forms be completed online using the Provider Enrollment, Chain, and Ownership System (PECOS). After all of your applications have been acknowledged as received, you can begin seeing Medicare beneficiaries. But remember to hold all claims until you are officially approved. Once you are approved, you can submit claims for services provided during the time period between when your application was received and when you were officially approved.

    Step 3. Fill out additional forms

    You will also need to fill out the following forms to complete your enrollment:

    • Medicare Participating Physician or Supplier Agreement – CMS 460 form
      By completing this form, you agree to accept payment directly from Medicare instead of the patient (except for the patient's 20% co-payment). "Participating" SLPs cannot charge more than the Medicare fee schedule amount. "Nonparticipating" SLPs are enrolled in Medicare but do not sign the CMS 460 form.
    • Electronic Funds Transfer (EFT) Authorization Agreement – CMS 588 form
      This form allows payments to be deposited directly into your bank account.

    Note: Learn more about Medicare enrollment for audiologists.

    Achieve Compliance in University Clinics

    In addition to applying for and enrolling in Medicare, there are numerous other factors to consider when determining how to come into compliance with Medicare regulations. Unfortunately, there is no “single fix” list of instructions to provide because each university program is structured differently. For example, some university clinics are associated with a university hospital; others are not. Leaders within the university’s system, including the university’s legal counsel, must determine how to proceed. Here are some key factors to consider.

    1. How many Medicare beneficiaries do you treat annually? If you treat only a handful of beneficiaries each year, you may choose not to see these patients. If Medicare beneficiaries make up 50% or more of your patient population, turning away Medicare beneficiaries may not be an option.
    2. How will you submit claims? Will you hire an internal billing person, use a billing service, or be nonparticipating and have beneficiaries submit their own claims?
    3. How will you meet the student supervision requirements? Determine if your clinic already has or can put into place sufficient clinical education staffing to provide 100% student supervision for the number of Medicare beneficiaries who will be seen at your university clinic.
    4. Can you partner with skilled nursing facilities or private practices in your area to provide clinical training and maintain Medicare student supervision requirements? Such partnerships could provide students with clinical experiences serving Medicare beneficiaries through facilities that have an infrastructure in place for Medicare billing and student supervision.

    Resources

    Questions? Contact ASHA’s health care and education policy team at reimbursement@asha.org.

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