Beneficiaries must be notified in writing of the expected out-of-pocket expenses related to an elective surgery that is not covered by their insurance over the amount of $500. The disclosure is required to be given by surgeons and assistants.
For the purposes of the Federal Medicare program an “elective” surgery is one where:
- It is scheduled in advance
- It’s not an emergency surgery
- If there was a delay in the procedure, it would not result in the patient death or permanent impairment.
Medical Billers Surgical Disclosure Notice
The OBRA at of 1986 (Omnibus Budget Reconciliation Act) mandates that the following information be included in the surgical disclosure notice in writing to the patient:
- Estimated actual charges for the surgical procedure
- Estimated Medicare payment
- How much more it will cost over the approved charges
- Any applicable coinsurance amounts
- Beneficiary (Patient) out-of-pocket amounts.
Non-participating provider surgeons need to get this notice signed and dated by the patient before doing the procedure. A copy of the document should, of course, be maintained in the patient file. The MAC may request ask to see it. If a non-par provider fails to properly notify the patient (beneficiary) before the procedure, any money paid by the beneficiary that exceeds Medicare-approved amounts will have to be refunded. Failure to do the refund can result in civil action and penalties from Medicare.
Here is what a sample Surgical Disclosure Notice looks like:
Name of Clinic —- Address —– Phone Number
Name of Beneficiary:____________________ Date:_________________
Type of Surgery/Procedure:_______________
Name of Provider__________________
Estimated Medical Payment Amount:____________________
Patient’s estimated payment including coinsurance amount:________________
Signature of Medicare Beneficiary/Date Signature of Provider/ Date
When working with surgical disclosure notices always keep a copy on file. ALWAYS authorize insurance and payment information and make sure as a medical biller that YOU understand what is going to be covered, what is not, and why? Make sure you have a clear understanding of what is elective surgery and what is not.
By: Dawn Moreno, PhD, CPC, CBCS, CMAA, MTC. Lives in the beautiful Southwest United States and has been an instructor for medical coding/billing for the past 7 years. Interested in quality medical billing training?