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Wednesday, April 18, 2012

"Areas of GREAT Concern" (Requests for Patient Records, Denials, Redetermination and Reconsideration aka The Appeal Process)

April 17, 2012
Chiropractic Medicare
"Areas of GREAT Concern"

Dear Doctors and Staff,

A huge area of concern is the Error Rate established by the Medicare Carriers across the United States.  67% of all claims billed to Medicare Carriers contained errors.  Some states the error rate is worse.  In Southern California the error rate is 77%!

After speaking with hundreds of DC's and their staff by phone I can assert that these people are not dumb.  The Inspector General, with "special" reports to our Senators and Congressmen, has given Congress an impression that Chiropractors are not too bright.

The First Problem is the incentive to learn. When (for example) the reimbursement for a 98940 is $24.56, the incentive to study and know all the Medicare Federal Guidelines seem pretty small.  Since about 96% of all Chiropractors in the U. S. are participating providers, either you don't get paid, or if you do get paid, there is always the fear of a Post-payment Audit and you end up paying everything back to the carrier.

To make the problem worse, more and more Medicare Carriers are simply denying all claims, first patient visit or 10th patient visit, whatever.  They know most Chiropractors do not know what to do next and the carrier wins.  A few Chiropractors who know a little of the Audit and Appeals process request a “Redetermination”.  This is performed by an individual at the Medicare Carrier not involved with the original determination.

At no surprise, usually the redetermination agrees with the original denial.  Usually 45 days have passed and the second denial is received.  Now the Chiropractor may request a “Reconsideration".  This is done by a "Qualified Independent Contractor" similar to first level of appeal.

Another 45 days pass and here comes another denial.  No surprise because it's from the same Medicare Carrier.  By now the Chiropractor has wasted 80 plus days, messed with patient records two or three times, all for $24.56.  Most DC's toss up their hands and give up.

If you will take those reviews and appeals to the next step and having done Medicare correctly, you have a great chance of winning.  When your appeal finally gets to the Administrate Law Judge (away from your Medicare carrier) you will most always win.  Just be sure you are doing Chiropractic Medicare correctly.

The Second Problem:  In several states like New York, New Jersey, Tennessee, California, Wyoming, etc., the Medicare Carriers consistently ask for all patient records that are billed by a Chiropractor.  Some states back log of patient records is unbelievable, however, they continually keep asking for records, and until they are reviewed, not one claim is reimbursed.

There seems to be some loss of government control with these specific carriers.  I recommend the State Chiropractic Associations in these states contact their Congressmen and Senators and file formal complaints against this action as quickly as possible. It is very possible the system is being abused by the Medicare carriers.

Most Important:  You have to know how to do Medicare correctly and become Compliant!
Have questions? Give Dr. Street a call today at (618) 395-3800.

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*Thursday, April 19, 1:00 pm - 5:00 pm at the Chariot Hotel - Louisville, KY

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