If it is not medically necessary for a patient to be personally reassessed prior to prescription renewal,
specialty referral, release of laboratory results, etc., claims for these services must not be made to
MSP regardless of whether or not a medical practitioner chooses to see his/her patients personally or
speak with them via the telephone.
Some services listed in the MSC Payment Schedule have fees which are specifically intended to cover
multiple services over extended time periods. Examples are most surgical procedures, the critical
care per diem listings and some obstetrical listings. The preambles and Schedule are explicit where
these intentions occur.
When, because of serious complications or coincidental non-related illness, additional care is required
beyond that which would normally be recognized as included in the listed service, MSP will give
independent consideration to claims for this additional care, if adequate explanation is submitted with
the claim.
Medical Research
Costs of medical services (such as examinations by medical practitioners, laboratory procedures,
other diagnostic procedures) which are provided solely for the purposes of research or
experimentation are not the responsibility of the patient or MSP. However, it is recognized that medical
research may involve what is generally considered to be accepted therapies or procedures, and the
fact that a therapy or procedure is performed as part of a research study or protocol does not preclude
it from being a service insured by MSP. In the situation where therapies or procedures are part of a
research study, only those reasonable costs customarily related to routine and accepted care of a
patient’s problem are considered to be insured by MSP; additional services carried out specifically for
the purposes of the research are not the responsibility of MSP.
Experimental Medicine
New procedures and therapies not performed elsewhere and which involve a radical departure from
the customary approaches to a medical problem, are considered to be experimental medicine.
Services related to such experimental medicine are not chargeable to MSP.
New therapies and procedures which have been described elsewhere may or may not be deemed to
be experimental medicine for the purposes of determining eligibility for payment by MSP.
Until new procedures or therapies are proven by peer-reviewed studies and adopted by the medical
community, they are experimental. Services related to such experimental medicine are not the
responsibility of the Medical Services Plan.
Coverage:
• Associated costs for any routine follow up care and diagnostic procedures related
to experimental medicine are the responsibility of the patient.
• Care related to complications of any treatment, including experimental medicine, is
covered by the Medical Services Plan. Care may include direct telephone
consultation with physicians as required and clinical services provided directly to
patients. Physician claims are billed under existing mechanisms through the
Medical Services Plan Fee-for-Service system
No comments:
Post a Comment