When does Medicare require that a patient sign a "waiver of liability"?
ACR Bulletin
May 2000
Coding
Medicare requires that patients sign waivers when services that are usually covered may be denied as unreasonable and unnecessary for the diagnosis, condition or treatment submitted. The most common scenario occurs when a diagnosis code that is not listed as an appropriate reason for a procedure under a Local Medical Review Policy is denied by the carrier as "not medically necessary." Waivers also would be required for procedures or services performed more frequently than listed in the Medicare exclusions from coverage guidelines. Two procedures that fall into this category are screening mammograms and colorectal cancer screens performed more frequently than provided for by Congress.
Medicare guidelines state that the patient must be notified in writing that Medicare will likely deny payment for the service, as well as the reason for the denial, prior to the service being performed. If the patient is not notified prior to the procedure and does not sign a waiver, the patient cannot be held responsible for the unpaid claim.
The radiologist must append a "GA" modifier to the procedure code listed on the claim form to indicate to Medicare that the patient was notified before the procedure, and that a signed waiver is on file. The GA modifier eliminates the need to submit a copy of the signed waiver with each claim. However, the radiologist/physician is required to keep a copy of the waiver on file and to submit a copy, if requested, to the Medicare carrier.
Be sure to differentiate "not reasonable and medically necessary" denials from "noncovered" service denials. Noncovered services (i.e., services excluded by law or under a nonbenefit category) do not require that a waiver be signed, and the patient is responsible for payment.
May I use a blanket waiver form for all Medicare patients? Does Medicare require specific language in the type of waiver used?
Medicare will not accept a blanket waiver in which the patient agrees to pay for any service(s) performed that Medicare may not cover; however, a standardized waiver form can be developed and the varying information may be filled in as required. A waiver must be signed for each service the radiologist, radiation oncologist or radiology practice believes may be denied. The following is standard language to be used in a notice/waiver that will satisfy Medicare requirements for an advance beneficiary notice. The waiver should be on your practice's letterhead or contain the name and address of your practice.
It should be noted that this provision does not apply to Medicare health maintenance organizations, competitive medical plans or to other prepaid health care plans.
A detailed explanation of the Limitation of Liability provision can be found in Chapter VII of your Medicare Carrier's Manual under section 7300.
If you have any questions concerning this article, please call the ACR's economics and health policy department at (800) 227-5463, ext. 4584.
