You are using an outdated browser. Please upgrade your browser to improve your experience.

You are here

Medicare Policy Topics

Screening vs. Diagnostic Mammography
Handling Concerns Regarding Carrier Policies
Provision of Itemized Statements to Beneficiaries

Screening vs. Diagnostic Mammography

I realize that Medicare now provides more frequent coverage for screening mammography, however how does Medicare distinguish a "screening" mammography from a "diagnostic" mammography?

Medicare's definition of "screening mammography" is contained in the Code of Federal Regulations (CFR) Title 42, Part 410, Section 410.34(a). It read: "Screening mammography means a radiologic procedure furnished to a women without signs or symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician's interpretation of the results of the procedure."

Conversely, Medicare's definition of a "diagnostic mammography," also contained in CFR 42, 410.34(a), reads: "Diagnostic mammography means a radiologic procedure furnished to a man or women with signs or symptoms of breast disease, or personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician's interpretation of the results of the procedure.

Handling Concerns Regarding Carrier Policies

How can I make sure my concerns about my Medicare carrier's policies are reaching the appropriate decision-makers?

CMS has procedures for pursuing concerns about a carrier's policy. (Note that there is a separate, established appeals process for adjudicating individual claims.) If you believe that your carrier has implemented an onerous policy or has misinterpreted a Medicare policy, follow these steps:

  • Contact your professional service representative. If you do not know who your representative is or you do not have one, call your carrier's provider line. Talking to a provider representative allows you to determine whether a policy problem actually exists and will help rule out any simple explanations. This step also keeps you from using your resources to challenge a justifiable policy.
  • If you determine that there is a legitimate problem, contact your carrier medical director (CMD). In your written correspondence with your CMD, you should outline the carrier's policy as you understand it (be sure to document your conversation with your professional service representative or your call to the provider line); explain why you think the policy is inappropriate; illustrate the impact the policy has had on you and your patients; and ask for a response.

Contact ACP if you need assistance in drafting a letter to your CMD. In addition, send a copy of the letter to your ACP Governor and to ACP headquarters.

If you cannot resolve this issue at the carrier level, bring it to the attention of your regional CMS office, which oversees Medicare's contract with your carrier. If you need assistance in dealing with your CMS regional office, contact your state chapter. If your chapter cannot help, send the materials necessary to pursue your case to ACP headquarters. Keep in mind, however, that the regional office will usually only intervene in carrier misapplications of national Medicare policy. When appropriate, ACP will contact the CMS central office to seek resolution. CMS wants to know about carrier activities that are inconsistent with national policy but insists that complaints proceed through the established chain of command.

Provision of Itemized Statements to Beneficiaries

I heard that Medicare plans to notify beneficiaries that they can request an itemized list of the services furnished by their provider(s). How will that process work?

Section 4311 of the Balanced Budget Act of 1997 (BBA 97) gives Medicare beneficiaries the right to submit to their provider or supplier a written request for an itemized statement for any Medicare item or service. This provision was included in the BBA 97 to encourage beneficiaries to carefully review their medical bills and to enlist them in fighting fraud and abuse.

Medicare contractors issue beneficiaries an Explanation of Medicare Benefits (EOMB) or a Medicare Summary Notice (MSN) to inform them of Medicare's payment decisions regarding claims submitted on their behalf by their physician or other health care provider. CMS recently instructed its contractors to include language on all EOMBs and MSNs informing beneficiaries of their right to request an itemized statement. Beginning April 1, 1999, most carriers will include the following language on EOMBs and MSNs:

"You (the beneficiary) have the right to request an itemized statement which details each Medicare item and service which you have received from your hospital, physician, or any other health care supplier or health professional. Please contact them directly if you would like an itemized statement."

What should an itemized statement entail?

CMS expects providers and suppliers to provide beneficiaries an itemized statement using their internal billing or accounting system. While the law does not specify what information should be included in an itemized statement, CMS recommends that an itemized statement contain the following elements:

  • name of beneficiary;
  • date of service;
  • description of item(s) or service(s) furnished;
  • number of services furnished;
  • provider/supplier charges; and
  • an internal reference or tracking number.

CMS notes that providers can include the following additional information if the claim has been adjudicated by Medicare:

  • amounts paid by Medicare;
  • beneficiary responsibility for co-insurance; and
  • Medicare claim number.

CMS also recommends that a response include the name and telephone number of a contact person so beneficiaries can call if they have any questions. You should not charge a beneficiary for an itemized statement.

What is the process for handling beneficiary inquiries for an itemized statement?

CMS envisions that this information will enable beneficiaries to reconcile an itemized statement with the corresponding EOMB or MSN. Contractors will direct beneficiaries with questions to the appropriate provider. The provider is expected to assist the beneficiary in understanding any discrepancies between the two documents.

Customer service representatives at Medicare carriers will attempt to resolve any questions by explaining applicable Medicare reimbursement rules.

Beneficiaries may ask their contractor to review a claim based on information contained in an itemized statement. Beneficiaries must submit requests to the contractor in writing and should identify the specific item(s) or service(s) that the beneficiary believes was not provided as claimed. Contractors may ask providers for help in examining the itemized statement as they review beneficiary complaints. When appropriate, contractors will seek to recover overpayments. The government can also impose penalties for cases involving true fraud.

What are the penalties for failing to comply with a beneficiary request for an itemized statement?

The law specifies that providers who do not comply with a request within 30 days can be subject to a civil monetary penalty of $100 per unfulfilled request. However, CMS assured ACP that it would not seek to impose financial penalties without first ensuring the provider actually received a request and was given multiple opportunities to respond to it.

Last updated: 12/17/2015