Nov-Dec 2005 Table of Contents

A Refresher on Medicare and Concurrent Care

Here’s how to get paid when you’re not the only doctor in the hospital room.

Fam Pract Manag. 2005 Nov-Dec;12(10):29-30.

Family physicians often treat hospitalized patients with complicated conditions that require other specialists’ involvement. For example, a patient hospitalized with diabetes mellitus and a serious heart condition might need your care as well as that of a cardiologist. While such concurrent care seems straightforward from a clinical perspective, it can be anything but when it comes time to submit your claims, especially to Medicare. To increase the likelihood that Medicare will pay for your services in a case like this, you need to understand how Medicare defines and covers concurrent care.

What is it?

From a Medicare perspective, concurrent care exists “where more than one physician renders services more extensive than consultative services during a period of time.”1 Practically, this translates into two or more physicians billing the same service (usually subsequent hospital care) for the same patient on the same date, sometimes with the same diagnosis. In the example above, concurrent care would occur if both the family physician and the cardiologist submitted a claim to Medicare for subsequent hospital care provided to the same patient on the same date of service, especially if they both listed the heart condition as a diagnosis on their claim forms.

Note that under Medicare’s definition, a consultation with another specialist wouldn’t be considered concurrent care. Thus, if the cardiologist provided an inpatient consultation at the request of the family physician and billed Medicare for a consultation rather than subsequent hospital care, concurrent care would not be an issue.

Getting paid for it

So how do you get Medicare to pay for concurrent care when it does occur? First, you need to understand that when more than one physician has an active role in a patient’s treatment, Medicare requires the care to be “reasonable and necessary.” To determine whether the concurrent care that you and other physicians provide is reasonable and necessary, Medicare uses the following (somewhat circular) criteria:

  1. The patient’s condition must warrant the services of more than one physician on an attending (rather than consultative) basis.

  2. The individual services provided by each physician must be “reasonable and necessary.”

To establish whether the services meet the first criterion, the Medicare carrier will consider each physician’s specialty and the patient’s diagnosis (or diagnoses) to determine how they align with Medicare’s definition of concurrent care (i.e., that the patient’s condition requires diverse, specialized medical or surgical services). That means Medicare is less likely to view concurrent care as reasonable and necessary if it’s provided by physicians of the same specialty or by physicians with a similar knowledge base. For example, if a family physician and a general internist provided care for our hypothetical patient, Medicare might question the claim because the skills and knowledge of a family physician and a general internist overlap and may not be different enough, at least in Medicare’s eyes, to necessitate active care from both physicians.

It also means that distinct specialties and distinct diagnoses can go a long way toward establishing the medical necessity of concurrent care and getting those services paid. Thus, in our example, the medical necessity of the concurrent care services may be at least partially established by the distinct specialties involved (i.e., family medicine and cardiology), especially if they use different diagnoses (e.g., if the family physician attaches a diagnosis of diabetes to his claim and the cardiologist uses a diagnosis for the heart condition on his claim).

What if the Medicare carrier determines that the patient does indeed require care from more than one physician? This still doesn’t ensure payment. The individual services must also meet Medicare’s standards for “medical necessity,” just as they would if only one physician were providing the care. For example, if the services you provided to our hypothetical patient exceeded Medicare’s standards for frequency or duration, then Medicare might still deny payment for them, just as it would if the patient was not receiving concurrent care.

In addition, one physician’s services must not duplicate those provided by another. For example, if both the family physician and the cardiologist were to make a postoperative courtesy visit to our hypothetical patient, the carrier might consider the visits duplicative.

Ultimately, the best way to ensure that your claim for concurrent care gets paid is to file it before the other physician. Often, whoever gets it to the Medicare carrier first will be paid. To make sure your claim gets there first, call your office from the hospital immediately or do it first thing in the morning, and tell your billing office to electronically submit a claim that day for that service.

The hassle factor

If you receive a denial on a claim for concurrent care and you believe it meets the Medicare coverage criteria above, consider appealing the denial. Because the Medicare carrier must determine whether the patient’s condition warrants the services of more than one attending physician in that situation, you should anticipate that the carrier will ask for more than the usual documentation for concurrent care claims.

The hassle factor might be a little greater with concurrent care claims, but Medicare does cover them. You should never let a Medicare carrier tell you otherwise. Knowing when Medicare covers them can go a long way toward ensuring you get paid for the concurrent care you provide.

About the Author

Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

 

1. Medicare Benefits Policy Manual, Chapter 15, Section 30.E. Available at: http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf. Accessed Sept. 30, 2005.

Copyright © 2005 by the American Academy of Family Physicians.
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