Help! My patient has Medicare and Medicaid, what do I do?

From time to time our office receives this question. You are a Non-participating chiropractor, your patient has Medicare and Medicaid, and you are unsure how to bill. 

Remember: ALWAYS BILL MEDICARE FOR A COVERED SERVICE. As a chiropractor, the only covered service in Medicare is the manual manipulation. However, the question was how to bill, so let's get to that.

As a Fee-For-Service Non-participating Provider in Medicare, you must accept assignment on a patient with Medicare Medicaid. You are allowed to collect unmet deductibles for Medicare. (Most of the time we take a small monthly payment plan for these individuals to meet that as they are on a budget.) They are on a fixed income and have met certain income criteria to be on the federal programs, no matter what the age. You must bill the covered service (the chiropractic adjustment) and mark box 13 as signed and 27 as accept assignment. For all other services you provide (that are not covered such as x-rays and therapies) make sure to have them sign the ABN notifying them at the time that these are not covered services, you are not required to bill those, and you may collect payment for those services.

Reference for Medi-Medi payment/billing requirements: (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf)

            "Assignment - You must accept assignment for services furnished to dual eligible beneficiaries. Assignment means that you are paid the Medicare-allowed amount as payment in full for all Part B claims for all covered services for all Medicare beneficiaries. You may not collect from the beneficiary any amount other than the unmet deductible and coinsurance. Prohibited Billing Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing)."

Reference for covered services: (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf)

            "30.5 - Chiropractor’s Services (Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04) B3-2020.26 A chiropractor must be licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which the services are furnished. In addition, a licensed chiropractor must meet the following uniform minimum standards to be considered a physician for Medicare coverage. Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered. If a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the x-ray can be used for documentation. However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor. For detailed information on using x-rays to determine subluxation, see §240.1.2. In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand-held with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device."

Reference for ABN use: (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractors_fact_sheet.pdf)

                "Option #2: A beneficiary selects option #2 when s/he agrees to pay out of pocket for the service in question and does not want a claim sent to Medicare. In accordance with the ABN, the provider would not file a claim, and the beneficiary would not have appeal rights since no claim is being submitted. (Please note that the patient can change his/her mind at a future time and request the claim be submitted.)"

Be a Chiropractor in Medicare

Be a Chiropractor in Medicare........Where in the federal law does it say we are supposed to “treat” our patient's pain and symptoms like other health care providers? It doesn't!
The federal law says our job as a Chiropractor is to locate and correct vertebral subluxations. So why do some Chiropractors “treat” their patient's symptoms until the symptoms are gone calling the adjustments “maintenance" or "wellness care” and not bill those adjustments for reimbursement? When the Chiropractor adjusts the Medicare patient, correcting vertebral subluxations, that is the covered service in Medicare. The doctor’s job is to learn how to “document” the need for the Chiropractic adjustment so our senior patients are reimbursed.

More ABN discussion

Newsletter from February 18, 2013
“ABN Advanced Notice of Non-coverage”

NOTE: This is the only document in your office that can not be stored electronically. It must stay in the original paper form. Either stored per patient or by date for fast recovery if requested by your Medicare carrier.

THE ABN
It has become my conclusion the ABN in it’s origination has but one primary purpose....to cut reimbursement by the Medicare Carrier. It contains rules that supersede the Federal law of mandatory claim submission. It has led many a Chiropractor down the yellow brick road of “Treating Patient Symptoms” instead of locating and correcting vertebral subluxations like Federal Law indicates.
When a Chiropractor calls the chiropractic adjustment that corrected a vertebral subluxation “Maintenance Care”, and had the patient check Option 2 on the ABN to not bill Medicare because it is called “Maintenance Care” since the patient felt no symptoms...and then collected from the patient, the regular office fee (not the Medicare fee) at the time of visit....Who Got Had?
The consumer (patient) just got cheated out of Medicare reimbursement. They pay over $100 dollar premium for Medicare each month. You say the patient had no symptoms. Consider this, as many as 1,800,000 seniors over the age of 65 may be dependent on Medicare-provided prescription drugs. The average number of prescriptions per year for each senior is 38.5 with the average number of different prescriptions daily being 5 or more.
Most of our patients are on 5, 6, 8, 10 drugs each day....they can not feel their symptoms. And yet, if the patient has no symptoms we just call it “Maintenance Care” and then not bill Medicare. I don’t think so! Our job as Chiropractors is quite clear in Medicare. We do not get paid to “treat” symptoms. We are only paid in Medicare to locate and correct vertebral subluxations.
If the patient have a subluxation and no pain symptoms....How about that subluxation of T6 spinal nerve and the trajectory of that nerve to the stomach, altering the normal function of the stomach. They are already on three prescription drugs for a stomach problem. S.O.A.P. notes shall indicate your findings, and your documentation will support the care given. I recommend, when you correct a vertebral subluxation, call it what it is....The primary job you do, and it is covered by Medicare. Help your patients get reimbursed in Medicare for the Chiropractic covered service of correcting a subluxation.

"ABN - Important!" ~Newsletter 8/14/12

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Newsletter
August 14, 2012
Chiropractic Medicare
"ABN - Important!"

 

If a patient selects Option #2 on the ABN, the service indicated on the ABN does not then become a non-covered service.  However, the doctor does not have to file a claim to Medicare in that particular instance because the patient indicated that he or she agrees to pay out-of-pocket and does not want a claim submitted to Medicare. (However, the patient can change his or her mind, at a future time, and request the provider to submit a claim to Medicare.)  Both participating and non-participating providers are permitted to ask for payment from the patient at the time of service if either Option 1 or Option 2 is selected on the ABN.

 

It is my opinion that the purpose of the ABN, a rule that supersedes the Mandatory Claims Submission Law, is a simple attempt to supply a process to not bill Medicare for our seniors so the carrier's do not have to reimburse for Chiropractic adjustments.  That is a deceiving way to cheat our seniors from reimbursement in Medicare in which they have already paid, plus they pay a Medicare premium each month for coverage.  I strongly recommend we Chiropractors provide great Chiropractic care to the seniors, learn the correct way to do Medicare and bill Medicare so our seniors get their due reimbursement.

 

Remember...the ABN should only be presented to patients when the service in question may be denied by Medicare due to medical necessity.  It is not appropriate for the provider to present a patient with an ABN for a service that is expected to be covered.

 

The Chiropractic adjustment is ALWAYS a covered service by Federal Law and it is the responsibility of the Chiropractor to learn and provide "documentation" so the covered service is payable.

Beginning of JUNE Newsletters 2012

Beginning  of JUNE Newsletters

(Sent out June 4th, 12th and 18^th)

Chiropractic Medicare

Sent June 4^th, 2012

Dear Doctors and staff,

Those using our recommendations in doing Medicare are having great success when addressing pre and post payment reviews and audits.  I do not know another Chiropractic Medicare training program that uses the "documentation" we suggest.  The documentation used with our program is Federal Documentation and supports the Chiropractic truths in caring for seniors.  Once you see and understand our presentation you will realize its the truth and the way it is with seniors.

Until you understand how Chiropractic works with Medicare, several items on your claims will indicate to the Medicare carrier you do not have it together, which usually brings on reviews and audits.  We chiropractors do not "treat" patient symptoms.  Our only job is to locate and correct vertebral subluxations.  The lack of documentation (and documentation is not S.O.A.P. notes), date of current over 60 days old and/or a diagnosis that does not support the care rendered and this claim will "pop" out of the carrier's computer for review.

If the review reveals the doctor does not know how to document and/or has a patient on a program of care for a condition that is over 60 days old or more than 12 visits, the carrier will now ask for more records as they now believe they can get some money recovery from this doctor.

It is critical to understand the "philosophy" of Chiropractic Medicare, to deal with Medicare like a Chiropractor and "STOP" treating patients in regards to their symptoms.  Revisit your thinking when doing Medicare.  Evaluate your Medicare patients as a Chiropractor.  Nearly all your Medicare patients do not have new conditions and new diagnosis.  They have exacerbations in direct relation to chronic predisposed arthritic subluxations.

Hardly ever do you see a new condition with a senior patient.  That should spark your thinking.  Once you understand chiropractically how Medicare works, learn the correct way to "document", understanding the honest "diagnosis", you will find Medicare an excellent Chiropractic program.

With an understanding of the correct way to do Chiropractic Medicare, now you can use your energy in becoming Medicare Compliant by the end of 2012.

      

Spring 2012 Seminar Schedule:

*Thursday, June 21, 8:00 am - 12:00 pm at Comfort Inn & Suites, Mount Laurel, NJ

*Thursday, June 21, 5:00 pm - 9:00 pm at Holiday Inn, Saddle Brook, NJ

*Saturday, June 23, 8:00 am -12:00 pm at Holiday Inn Express University, Albany, NY

*Thursday, June 28, 8:30 am - 12:30 pm at Holiday Inn Express, Mishawaka, IN

  (4 hrs. Risk Management Continued Education - add $35.00 to registration)

  Have questions? Give Dr. Street a call today at (618) 395-3800.

Sent June 12^th, 2012

“ABN Option #2 - Covered and Non-Covered Service”

Albany, New York, Mount Laurel and Saddle Brook, New Jersey and Mishawaka, Indiana are upcoming Chiropractic Medicare Seminars for the month of June.  In those seminars I will cover the "Basics" Chiropractic Medicare information and review the steps on becoming Medicare Compliant.  If you have not attended one of our presentations, please call and register.  I promise you will receive information you will be happy to have… plus have fun.

ABN Option #2

For the Chiropractors that are "treating" patient symptoms, Option #2 on the ABN is dangerous.  Many Chiropractors "believe" when a patient has no symptoms, just call the Chiropractic adjustment "Wellness Care" or "Maintenance Care" and that way they "believe" they do not have to bill Medicare for the Chiropractic adjustment.

The patient signs Option #2 on the ABN and the doctor believe the adjustment is now a "non-covered service" in Medicare.  So not only does the doctor NOT bill Medicare for the Chiropractic adjustment. the doctor also collects from the patient at time of service for the Chiropractic adjustment, even though the doctor is a participating provider.

As a Participating Provider, your Federal Contract says that you can NEVER collect the 80% of the set Medicare fee for the adjustment at time of visit. You must ALWAYS accept assignment on a Medicare patient.  The Chiropractic adjustment is ALWAYS a covered service by Federal Law.  It may not be payable, however, by Federal Law, it is the only covered services for we Chiropractors.

Option #2 is for ONLY a non-covered service.  Simply, the Chiropractic adjustment must always be billed to the Medicare Carrier and Option #2 has nothing to do with a covered service. 

Remember: the fines are up to $10 thousand dollars per incident when not billing a covered service.

Sent June 18^th, 2012

“Audits, Appeals and Record Requests”

All Chiropractors and staff first must know the correct way to do Chiropractic Medicare.  When done correctly, your Medicare Carrier will recognize you are doing it correctly on your claim form and will stop asking for your records.

As far as I know, our Chiropractic Medicare Program is the only one presenting "documentation" by federal standards.  That information is entered in Item #19 on the initial claim, so the Medicare Carrier recognizes you have the "Documentation."  This information will cut most of the records requests.

The Appeals Process is fair; however, the first two steps of the Appeals Process (Request for Redetermination and Reconsideration) are still with the Medicare Carrier.  Due to the hassle and time frame dealing with Step 1 and Step 2, most Chiropractors either have done Chiropractic Medicare wrong or simply "give up"!

The third step in the Appeals Process (Request for Administrative Law Judge Hearing) is outside your carrier. If you have "documented by Federal Standards" you will be successful.

  Have questions? Give Dr. Street a call today at (618) 395-3800.