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January 4, 2002
Discriminatory practice in the Medicare program affecting people with Alzheimer’s will no longer be allowed, according to a new program memorandum issued by the federal Centers for Medicare and Medicaid Services (CMS).
Prior to the new policy, when a patient was given a primary diagnosis of Alzheimer’s disease or any other form of dementia, some Medicare carriers and intermediaries restricted or denied certain medical services immediately, even though they were commonly covered by Medicare in people without Alzheimer’s disease.
The new policy states that contractors may not use computer edits that result in the automatic denial of services based solely on the codes for Alzheimer’s or dementia. Throughout the course of their disease, individuals with Alzheimer’s disease or dementia may benefit from physical, occupational, speech-language and other therapies, all of which were denied by some carriers and intermediaries.
CMS explains, “a claim submitted with only the diagnosis of Alzheimer’s disease may entitle a beneficiary to evaluation and management visits and therapies if a contractor determines that these therapies are reasonable and necessary when reviewed in the context of a beneficiary’s overall medical conditions.”
Providers will be instructed to enter the primary diagnosis or condition as well as the secondary diagnosis that most closely reflect the medical necessity of the service. And, when a beneficiary with dementia experiences a health problem unrelated to the dementia, the provider should submit a claim with a primary diagnosis that most accurately reflects the need for the provided service.
The policy change was advocated for by the Alzheimer’s Association’s Medicare Advocacy Project, a collaborative project of the Association and the American Bar Association Commission on Legal Problems of the Elderly.
According to Leslie Fried of the Alzheimer’s Association’s Medicare Advocacy Project, most people with Alzheimer’s have been in a ‘Catch-22.’ Medical researchers and clinicians encourage the early diagnosis of Alzheimer’s disease in order to maximize the benefits of early intervention and treatment. However, early diagnosis of the disease had often resulted in the denial of Medicare coverage and subsequent denial of access to care.
“The new policy should begin to eliminate the discrimination people with Alzheimer’s had been experiencing. However, for this policy to really make needed medical care available for people with Alzheimer’s, insurance carriers and intermediaries must begin to implement the new ruling,” said Fried. “An education program is needed to alert carriers of the rule. We are encouraged that the process should move quickly since CMS has been very responsive to the needs of this community.”
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