What are Non-Covered Services in Medical Billing?

non-covered services in medical billing

Do you want to provide your patients with the best possible service? You can improve their satisfaction by helping them understand the non-covered services in medical billing, as well as the most common denials in medical billing.

A team like PracticeForces can also help you and your patients understand the complicated insurance and billing process, especially when it comes to Medicare. Read on to discover the basics of non-covered services.

What Non-Covered Services Mean

Any medical procedure or product that a governmental or private insurance company won’t cover falls under non-covered medical services. So, to provide the best level of service to your patients, you should alert them about a procedure that may not receive coverage from their insurance provider. They’ll pay out of pocket instead.

How Companies Determine Non-Covered Services

Insurance companies use the following local coverage determinations and national coverage determinations to decide what to cover.

Medical Necessity

Is the service medically necessary or reasonable? Then the insurance company will provide some level of coverage. 

Most entities use the following criteria to determine medical necessity:

  • Was it caused by a covered treatment, illness, or injury?
  • Is it a standard procedure (non-experimental) according to professional medical standards?
  • Is the procedure not overwhelmingly for the convenience of the patient or physician?
  • What would ensure the highest level of safety and efficiency for the patient?

Overlap

If a service or product is normally bundled into or provided by another service, the company won’t cover it. This also happens if other organizations, such as charities, provide reimbursement for the same service or product.

Common Non-Covered Services

While each insurance plan is different, the following are the most common non-covered services in medical billing:

Cosmetic Surgery

Medical coverage providers deem any surgery that addresses a purely aesthetic issue, rather than a functional defect, unnecessary. A nose job or plump lips will be out of pocket.

Dental

Nearly all dental services will not fall under traditional insurance coverage. Patients have to purchase separate dental insurance, including standard visits, root canals, and extractions.

Foot Care

Orthotics, foot hygiene, and preventive maintenance are examples of foot care that medical insurance does not cover.

Hearing Aids

Insurance companies seldom consider hearing aids a medical necessity and may not cover examinations, fittings, or the purchase of listening devices.

Custodial Care

Might your patient need long-term care? Health insurance won’t typically cover longer than 80 or 100 days.

Routine Check-Ups

Non-covered routine services include a wide variety of common practices, including eye check-ups, elective vaccinations, and screenings. 

Comfort

While personal comfort items like pillows, seating pads, or special shoes improve your patient’s overall quality of life, they’re rarely deemed medically necessary.

Investigative Tools

When medical services require investigative tools beyond an active diagnostic process, insurance considers them a non-covered service.

Call PracticeForces for All Your Medical Billing Needs

Helping your patients understand non-covered services builds trust and streamlines your medical billing issues. PracticeForces can help with all your medical billing needs, whether it’s mastering a medical necessity denial or helping with collection.

Call PracticeForces at (727) 499-0351 today for more information about our services.

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