Remark code M38 is an alert indicating that the patient has previously been notified in writing that the insurance payer would not cover the charges for the provided service. The patient acknowledged this information and agreed to be responsible for the payment of these charges.
Common causes of code M38 are:
1. The patient received a non-covered service: The service provided is not included in the patient's insurance benefits, and the patient was notified in advance that the service would not be covered.
2. Advance Beneficiary Notice (ABN) was issued and signed: The healthcare provider issued an ABN to the patient, which the patient signed to acknowledge their financial responsibility for the service.
3. Elective procedures or services: The patient opted for a procedure or service that is typically not covered by insurance plans, such as cosmetic surgery, and agreed to pay out-of-pocket.
4. Experimental or investigational treatments: The patient was informed that the treatment is considered experimental or investigational by their insurance plan and agreed to bear the costs.
5. Services exceeding limits: The patient has exceeded the limit of covered services (e.g., therapy sessions) and was informed that additional services would be out-of-pocket.
6. Provider out of network: The patient received services from a provider who is not within their insurance network and was previously informed that the insurance would not cover charges from out-of-network providers.
7. Lack of medical necessity: The patient was informed that their insurance deemed the service not medically necessary, and they agreed to proceed with the service regardless of coverage.
8. Failure to obtain prior authorization: The patient was informed that the service required prior authorization, which was not obtained, and they agreed to be responsible for the charges.
9. Non-covered benefit under the patient's plan: The patient was informed that their insurance plan does not cover the specific service or item, and they agreed to pay for it themselves.
Ways to mitigate code M38 include implementing a robust patient education and consent process. Ensure that all patients are clearly informed about the potential for non-coverage for specific services. This should be done through a formalized Advanced Beneficiary Notice (ABN) or similar documentation that is provided to the patient prior to the service being rendered. Staff should be trained to explain the notice effectively and confirm patient understanding. Additionally, maintain meticulous records of these communications and consents, including patient signatures, to demonstrate that patients were fully informed and agreed to be responsible for the charges. Regularly review and update your notification and consent forms to align with any changes in coverage policies.
The steps to address code M38 involve verifying that the patient's acknowledgment of financial responsibility was obtained prior to the service being rendered. This should be a written document, such as an Advance Beneficiary Notice (ABN) for Medicare patients or a similar financial responsibility form for other payers, where the patient agrees to pay out-of-pocket for the services rendered. Ensure that this document is signed and dated by the patient and is on file.
Next, update the patient's account to reflect that the patient has accepted liability for the charges. If the patient has not yet been billed, proceed to generate an accurate bill for the patient, including all the charges they are responsible for. If the patient has already been billed and there is a discrepancy, reconcile the patient's account accordingly.
Communicate with the patient to remind them of their agreement and to arrange for payment. This may include sending a statement, setting up a payment plan, or discussing other financial arrangements. It is also important to document all communications with the patient regarding their financial responsibility in their account for future reference.
If there are any disputes or the patient does not remember agreeing to be responsible for the charges, be prepared to provide a copy of the signed acknowledgment. This will serve as proof of their agreement and help resolve any misunderstandings.
Lastly, review internal processes to ensure that patients are consistently being informed about services that may not be covered by their insurance and that they are agreeing to take financial responsibility for such services in writing before those services are provided. This will help prevent future occurrences of this issue.