Author Archives: Dave

NGS Medicare Fees for 2024 Chiropractic Services CMT

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CMS has now released the 2024 fee schedules for each State*. Note that these often change between the time they are published and the time they go into effect.

According to CMS, the 2024 Part B deductible will increase $14, to $240 as of Jan 1, 2024.

NGS Medicare has released the Medicare Physician Fee Schedule (the 2024 CHIROPRACTIC FEES SCHEDULE) for codes 98940, 98941, and 98942 for Par and Non-Par Part B providers (not Facilities) for dates of service Jan 1, 2024 forward.

Fees for Wisconsin are:

medicare NSG fees 2024

*States include: CT, IL, ME, MA, MI, NH, NY, RI, VT, WI

Insurance Key References

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Following is a list of links to various publications with helpful information on insurance filing guidelines and requirements.  At the bottom is a convenient downloadable document with all of this information listed.
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Wisconsin Worker’s Compensation Treatment Guidelines DWD CH 81.04
https://docs.legis.wisconsin.gov/code/admin_code/dwd/080_081/81

General. Except as set forth in par. (b) and s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in pars. (c) to (i) beyond 12 calendar weeks after any of the passive modalities in pars. (c) to (i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home. DWD 81.06(3)(a)

Wisconsin Worker’s Compensation Tx Guidelines Departure from Guidelines / Exceptions
DWD 81.04(5) (5) Departure from guidelines. A health care provider’s departure from a guideline that limits the duration or type of treatment in this chapter may be appropriate in any of the following circumstances:

Wisconsin Unfair Claims Settlement Practices
Ins 6.11  Insurance claim settlement practices.https://docs.legis.wisconsin.gov/code/admin_code/ins/6/11/3

Wisconsin Medicaid CMS1500 Claim Instructions
https://www.dhs.wisconsin.gov/forms/f0/f01234a.pdf
https://www.forwardhealth.wi.gov/kw/pdf/2008-89.pdf

Wisconsin Medicaid – New Requirements and Clarification of Chiropractic Services
https://www.forwardhealth.wi.gov/kw/pdf/2016-35.pdf

Documentation, SOI, 20 visit limit, exam clarification.
State of Wisconsin Insurance Equality
632.87(3) Wisconsin Insurance Equality Chiropractic

Medicare Supplement Mandated Benefits Wisconsin
https://oci.wi.gov/Documents/Consumers/PI-002.pdf
Medicare Supplement and Medicare SELECT policies cover the usual and customary expense for services provided by a chiropractor under the scope of the chiropractor’s license. This benefit is available even if Medicare does not cover the claim. The care must also meet the insurance company’s standards as medically necessary.

Wisconsin Provider Manual Anthem BCBS
https://www.anthem.com/docs/public/inline/PM_WI_00006.pdf

Wisconsin Anthem BCBS Commercial Reimbursement Policy
https://www.anthem.com/docs/public/inline/C-08010.pdf

Wisconsin Anthem BCBS Commercial Modifier Rules
https://www.anthem.com/docs/public/inline/Modifier_Rules_2021.pdf

Downloadable Reference Guide: Insurance Key References

Medicare Reimbursement Cuts Delayed in 2022!

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On December 10th 2021,  President Biden signed into law a bill to delay reimbursement reductions for physicians. Further, the proposed 2% sequestration reimbursement reduction to physician services as well as to farmers, has been delayed.

Please see the 2022 Wisconsin Chiropractic physician fee schedule below.

For your reference, here are the 2020 and 2021 Wisconsin Chiropractic physician fee schedules:

For over 35 years, Petty, Michel & Associates has been at the forefront of keeping up to date with CMS Medicare & Medicaid Service’s billing and coding standards. Questions? Contact us at 414-332-4511 or email Lisa-lisa@pmaworks.com

Source: https://www.jdsupra.com/legalnews/bill-averting-medicare-sequester-cuts-4029291/

For more details on fees and relative values in your practicing state, refer to your Medicare Administrator Contractor’s (MAC’s) website.

David Michel

Medicare Changes: National Government Services LCDs: Effective 12/1/2015

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*This notice specifically pertains to those offices where the Provider of Medicare is NGS:  CT, IL, ME, MA, MN, NH, NY, RI, VT, and WI.

 

For those of you who have NGS as their Medicare provider (states listed above), we wanted to make sure you were aware of a new policy which has some big changes, mostly positive and where you could get more information about it.

The NGS(National Government Services) recently published the new Chiropractic Medicare Policy which will go into effect on 12/1/2015

For more information on the chiropractic medicare policy visit:

L66315 Chiropractic Services Policy

Sincerely,
Dave

Preparation for the September 7 switch to NGS Medicare

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This shouldn’t be too big a deal, but there are a couple steps I want to make sure you are on top of. Obviously it would be best if you can attend one of the Wisconsin CSW Medicare seminars (here), but these are the basics:

  1. Make sure you have talked to your billing software company and your clearing house and that you have made any changes needed so that your Medicare claims goes to the correct place as of Monday, September 9.
  2. Do your final billing to WPS Medicare on Friday, September 6. That is the last day you can bill to them. Starting with dates of service September 7 or later, send those to NGS Medicare.
  3. You and the doctors should review the diagnosis that NGS Medicare allows for chiropractic claims. I have heard that there are slight differences, so this all has to be reviewed prior to submitting claims after the switch. Medicare Allowed Diagnosis Codes
  4. The new chiropractic policy for Wisconsin, Minnesota and Illinois is L27350 (here:LCD for Chiropractic Services) and has all the diagnosis allowed. Double check these on your Medicare patients. Any Dx not on this list will be denied.
  5. Doctors need to review all onset dates for all current Medicare patients to make sure that they are under active care, that they have an updated onset, and that documentation is in order (see #4 above).
  6. In order to document your objective goals and functional impairment, I strongly suggest you start using an outcome assessment tool every 30 days with all Medicare patients. In speaking to several clients, they like the Functional Rating Index. It is quick, easy for a Medicare patient, and very fast for the staff to score.
  7. You can find the FRI form for free at http://www.chiroevidence.com/FRI.html. There is a two page version or a one page version.

As always, call me if you have any questions, but these are the minimum basics that we have to be ready to move on.

Best, Dave

Chiropractic Maintenance Care: Medicare Settlement Means No More “Improve or You’re Out”

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In what could be a landmark decision for chiropractors that have long asserted that regular chiropractic care for seniors with chronic conditions actually saves Medicare money and keeps seniors active and independent, an agreement has been reached.

A Federal Judge has approved the proposed Settlement Agreement in the Medicare Improvement Standard case, Jimmo vs. Sebelius, [Link] clearing the way for thousands of Medicare beneficiaries to receive needed health services to maintain their current level of functioning. While not specifically aimed at chiropractic, the exciting implications remain.

The settlement, which represents a significant change in Medicare coverage rules, ends Medicare’s longstanding practice of requiring people to show a likelihood of improvement in order to receive coverage of skilled care and therapy services. It specifically pertains to “…those with disabilities or suffering from chronic illnesses such as Alzheimer’s disease, Parkinson’s disease, ALS, lung disease.” (ital added)

The Agreement, which is retroactive to the date of the suit was filed, January 18, 2011, includes skilled services covered by Medicare Part A and Part B, such as speech, occupational and physical therapy, nursing and home health services, even when the goal is maintaining the patient’s current condition rather than requiring that the patient improving.

The Medicare law has never supported the “”improvement standard.” Nevertheless, for decades beneficiaries have been denied needed services because they are not improving or have “reach a plateau”, sometimes with devastating results. The Center for Medicare Advocacy says providing maintenance services will save money in the long run, preventing decline, hospitalizations and need for more expensive services.

The official approval of the settlement means the Center for Medicare and Medicaid Services (CMS) must develop and implement an education campaign to ensure that Medicare providers are not denying coverage for vital maintenance services to those with any chronic illness who meet other qualifying Medicare requirements.

The “maintenance standard” is effective immediately. Importantly, this does NOT change anything at this time for you, your documentation, or your patients. Even though we have not seen the official documentation that Chiropractic Maintenance Care is included in this settlement, we are hopeful and following this closely.

More Info:
http://blog.aarp.org/2013/02/06/amy-goyer-medicare-pays-for-skilled-therapy-for-maintenance-with-chronic-illness/

New Medicare ABN Form for Chiropractic Offices

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Below you can find a link to a  sample version (in pdf)  of the new Medicare ABN Form that all offices must use starting January 1, 2012. Please download, review, edit name & address, and have your Medicare patients complete this form starting Monday.

If you have questions, see below. I tried to answer them the best I could, but contact me if you are unsure.
Thanks, and Happy New Year!
Dave

NEW MEDICARE ABN FORM – PDF

What is an ABN Form?

“The ABN is a notice given to Medicare beneficiaries to let them know that Medicare is not likely to provide coverage in a specific case. The patient must complete the ABN as described below before providing the items or services that are the subject of the notice.”

What do we need to do with this form?

First, you must put in your clinic name, address and phone number on the form. This is Medicare’s requirement. Have each Medicare patient review the form, check one of the three options, and sign the form. Keep a copy in the patient’s chart for the most current course of treatment.

Why are exams, xrays and therapies noted on the form?

The ABN can be used for both covered, but not medically necessary services (such as a wellness adjustment billed without the –AT modifier) or for non-covered services. Adding non-covered services, such as therapies or exams, helps Medicare patients better understand what will and won’t be paid.

Why is the “Estimated Cost” line left blank?

Because this will vary depending on what you are doing with the patient, whether the patient has a secondary, supplement, or alternative financial agreement with your office. This will be different for different patients. You can either estimate a “per visit” cost or the total cost for care. (per page 4, Form Instructions, ABN).

Please get rid of your older, blank ABN forms. More Questions? Ask Dave!

Chiropractic Prepayment Plans in South Dakota? Think Again!

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If you’re a chiropractor in South Dakota and you believe patients benefit from ongoing regular chiropractic care, or you think that you know what an appropriate treatment plan might be for your patient, AND you want to offer your patient a prepayment plan, guess again. You’ll find yourself before your State Chiropractic Board for unethical behavior.

That’s what happened to Dr. Josh Biberdorf, who has a few clinics in that State and also is the president of the South Dakota state chiropractic organization. Here’s a great article: http://rapidcityjournal.com/news/state-board-reprimands-chiropractor-for-billing-practice/article_e3b0eb8e-2f4d-11e1-815e-0019bb2963f4.html.

This is yet another example of State Chiropractic Examining Boards going after local DC’s for practicing their business within their scope of practice. Wisconsin and Minnesota continue to do this.

This begs the question of what the role of the state chiropractic board is. They are created to protect the public – that’s what the State law says. But more and more it seems that the State Boards like to determine what chiropractic is – whether patients, the public or chiropractors agree.

This is bad for patients, bad for the public, bad for chiropractic. No other profession does this to itself.

When, we ask, are chiropractors going to stop going after one another? It seems the biggest crime a chiropractor can commit within his or her own profession is to be successful. If you are, some piss-ant DC is going to report you to the board.

It’s time for the National Board of Chiropractic Examiners to make a clear statement on this and ensure that local Boards are doing what they are supposed to – protect the public. Not protect unhappy chiropractors.

Handling Insurance Company Refund Requests of Chiropractic Patients

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More and more, insurance companies are doing post payment audits or hiring outside firms to conduct payment reviews and requesting money back from your chiropractic office.

Refunds should never be automatically sent out based on a request from an insurance company.  Each request needs to be individually reviewed and processed and the patient’s account should be audited to determine if a refund is actually due and to whom.

Sometimes, a refund is due. Examples may be when an insurance company has double paid dates of service, or when two insurance companies both pay on the same date of service. These are legitimate refunds – ie: you have been paid more than you billed or were due for services rendered. These should be refunded.

Often however, a refund is NOT due and should be disputed. Examples might be when an insurance company or third party does a “post payment review” and determines that the care was not medically necessary, or when insurance pays but later determines that work comp or PI were primary, or when an insurance company decides that the patient did not have a particular benefit or coverage for what they already paid.

Essentially, when you have delivered quality services to a patient that were medically necessary and in the best interest of the patient, and the insurance company pays for those services, you have NOT been overpaid and no refund is due. Even if the insurance company later decides they overpaid or paid in error. These refund requests should always be disputed.

Legally, you are not obligated to repay the insurance company when you have been paid in good faith for services rendered and they paid in error. These should always be disputed.

This will not stop some insurance companies from ‘recouping’ the payment, but you should still attempt to dispute the refund request first. Our experience is that by disputing the refund you will avoid 85% of all refund requests. It is well worth the time and effort to do so.

The exception to the above involves government programs such as Medicare and Medicaid. We generally advise refunding these right away and THEN disputing the request. Remember that you must use the approved Medicare refund form and mailing address (check on line with yur local Medicare carrier for the latest form and address).

Points that can and should be used whenever disputing a refund include these (use any and all reasons that are applicable to each case):

– All services were medically necessary for the health of the patient. Our review indicated that the care was medically necessary; therefore no refund will be issued.

– This request is for a patient no longer active with our office. We have no alternative methods of collecting on these accounts. Because of a supposed error on your part, you are asking us to refund monies to you for services rendered to your insured without a foreseeable ability to collect for said services.

– We called/verified benefits on line with (Insurance Company) on each of these patients prior to the delivery of care and verified coverage for services rendered by our office. Had we been informed, we or the patient could have made a more informed decision regarding the delivery and payment for care.

– It is our understanding that (Insurance Company) has maintained a policy of not reimbursing for services if they are submitted for payment one year or longer after delivery. You are requested a refund for services over two years after their delivery and payment. It would seem that the policy should apply both ways.

– Your letter mentions that 98940 and 97140 are mutually exclusive. This is not the case when they are performed in different regions of the body as defined by the AMA. You also state that manual traction and mechanical traction are mutually exclusive. Again, this is not stated in the AMA CPT codebook and the services were performed by different providers, as our chart records show.

– The time and effort to have our office pull charts and research services from 2009 and 2010 is considerable and cannot be done without prior reimbursement, nor can these records be forwarded to (Insurance Company) without prior consent from the patient.

– We would also like to know if you have informed this patient, in writing, that due to the error on your part, that they are now liable for their medical bill from 2009?

– Our feeling is that the following court cases concluded that the insurance company is responsible for knowing their policy limits prior to paying and therefore must bear the responsibility for their own mistakes.

  1. City of Hope National Center vs. Western Life Insurance Company, 92 Daily Journal D.A.R. 10728, Decided July 31, 1992. (In this case the hospital obtained standard assignment of benefits from the patient and submitted claims, which were paid by the carrier. The insurance company later decided the treatment was experimental and requested the money back. The California Court of Appeals stated that if it’s your mistake you have to pay for it.
  2. In Federated Mutual Insurance Company vs. Good Samaritan Hospital (Neb. 1974) 214 N.W.2d 493. (The carrier contended that it mistakenly paid claims beyond the policy limits. The court held that the insurance company could not recover the money as it places an undue burden on the providers of service to subject them to retroliability.)
  3. Lincoln Nat Life Ins vs. Brown Schools (Ct.App. Tex 1988) 757 S.W. 2d 41 1. (In this case the carrier mistakenly paid claims after its policy had expired. The court denied recovery stating “Here the insurer knew it’s own policy payment provisions, but failed to notify the health care providers as to these provisions and the insurer alone made the mistake of paying beyond its responsibility . . . in the normal course of such business, the hospital has no responsibility to determine if an insurance carrier is properly tending to its business.”)
  4. National Ben. Administrators Vs. MMHRC (S.D. Miss. 1990). (Similar case as #3 with same conclusion.)

– Our office made no misrepresentations in filing claims for your insured. We extended valuable services based on preverification of benefits and assignment of payment by the insured. We were not unjustly enriched, and simply had no reason to suspect that any of the payments for services rendered were in error. Refunding the monies at this time would place an undue burden on our office.

As always, send a copy of your letter to the patients involved. The insurance company will send a letter to the patient (if we don’t send them a check) saying that “we are not cooperating and therefore the patient may be responsible”. So, strike first by presenting our side and preparing the patient.

Situation: The insurance company paid twice on one date of service and missed payments on another. They are now requesting repayment on the double payment.

Solution: Send them a letter explaining that the payments were posted to the unpaid dates and no refund will be made.

 

Situation: The insurance company claims that the work comp carrier is responsible for payment and is asking for all their money back.

Solution: Send them a letter explaining that you will bill the work comp carrier and if and when payment is received, you will refund any duplicate payment.

 

Situation: The insurance company paid for the first eight visits, then denied the next five and now wants a refund on what they paid.

Solution: Dispute the refund as per the above points and request immediate payment on the five denied visits.

 

Situation: The insurance company paid for care, but then came back and stated the patient didn’t have an active policy or coverage.

Solution: Dispute the refund as per the above points. It is the insurance company’s job to pay within the limits of their plan; you have been paid for services rendered.

If you have questions, feel free to contact me.

David Michel

Working with HSA / HRA / Flex-Spend Accounts in Your Chiropractic Office

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First, please understand the difference. Many chiropractic patients do not know what they have, so it is important that you understand these key terms.

Traditional Health Savings Account (HSA)

An HSA is a savings account set up to be used for medical expenses and nothing else. Funds directed to the HSA are pretax dollars, thus reducing taxable income, and HSA’s offer interest on the balance. The medical expenses and HSA can be used for include optical, insurance deductions, dental, chiropractic and some over-the-counter medications. Individuals who are covered by high deductible health plan (HDHP) are eligible to open an HSA.

Archer Medical Savings Account (MSA)

An Archer MSA is a tax-favored savings account designed to help you pay for qualified medical expenses if you are an employee of a small employer or a self-employed individual participating in a high-deductible health plan. Archer MSA assets may be rolled over or transferred to an HSA.

Health Flexible Spending Account (FSA)

A health FSA is an arrangement that allows employees to be reimbursed for medical expenses. Health FSAs are usually funded through voluntary salary reduction agreements with the employer. No employment or federal income taxes are deducted from contributions made to a health FSA. In general, balances in a health FSA at the end of a plan year cannot be carried over to the next year. For more information on health FSAs see IRS Publication 969,

Health Reimbursement Arrangement (HRA)

An HRA is an arrangement similar to a health FSA; however, an HRA must be solely funded by an employer. The contribution cannot be paid through a voluntary salary reduction agreement on the part of an employee. Employees are reimbursed tax free for qualified medical expenses up to the maximum dollar amount for a coverage period. Balances in an HRA at the end of a plan year can generally be carried over to the next year. For more information on health HRAs see IRS Publication 969,

Key Differences

The funds contributed to an HRA account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differentiates them from company-owned Health Reimbursement Arrangements (HRA) that are an alternate tax-deductible source of funds.

Billing Considerations for the Chiropractic Office

All of the above plans qualify for chiropractic reimbursement. The method of obtaining reimbursement varies by the plan type. Some plans will state that they do not pay for prepaid services. This is not accurate, as they will prepay for three years of orthodontic care (braces) and similar “pay upfront” services.

A FSA, or flex-spend account, only reimburses the patient for health care costs they have already paid. The patient must “use or lose” the money that has been put into their FSA each year.

An HSA plan is directed by the patient. They will have a card, similar to a credit card (and processed exactly like a credit card, not a debit card) that pulls from their HSA. This can be used for deductibles, co-payments and prepayments on discount plans.

An HRA plan is maintained by the employer and you must bill directly to the employer (in most cases) for reimbursement.

To avoid confusion for the patient and their HRA or FSA plan, the clinic must provide the patient a receipt or invoice showing that the patient has paid for the service. When a patient begins a treatment plan in your office, and you provide a discount for payment up front for the plan of care, the invoice should show that the patient paid for XX visits in your office. It should not indicate that the patient “pre-paid” for  a care plan as this will often confuse the plan and result in your patient not being fairly reimbursed.

Questions can usually be directed to the company’s human resource department.

Chiropractic offices should promote the fact that they can provide a “Discount for Using Your HSA / Flex Spend Account”. If you have established payment at time of service discounts, or prepayment discounts, encourage patients to use these by promoting the savings they can get. People with these plans are well aware of how quickly they can burn through their heath care dollars and welcome an opportunity to save.

Using HRA Money for Supplements & Vitamins in a Chiropractic Clinic

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Recent changes due to the Affordable Care Act change how patients may use their HRA or flexspend accounts. These changes took effect on Jan 1st of this year. Here was our answer to Mary, a great Front Desk Coordinator who is on top of this.
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Good Morning Dave,

I have a question. Many of our patients have flex accounts but because of the new laws about not being able to buy over the counter and being reimbursed by the flex accounts I am running into problems with our supplements.

Do you think we could get around this if the Chiropractor wrote on a script card that they (the chiropractor) have recommended the supplement to the patient?

Please let me know what your ideas are on this subject.

Thanks,

Mary

– – – – – – – – – – – – – – – – – – – – – – – – – — – – – – –

Hi Mary,

Great question, you are the first to ask that one, so you get the award! 😉

According to the IRS website (http://www.irs.gov/newsroom/article/0,,id=227308,00.html),

Q. How are the rules changing for reimbursing the cost of over-the-counter medicines and drugs from health flexible spending arrangements (health FSAs) and health reimbursement arrangements (HRAs)?

A. Section 9003 of the Affordable Care Act established a new uniform standard for medical expenses. Effective Jan. 1, 2011, distributions from health FSAs and HRAs will be allowed to reimburse the cost of over-the-counter medicines or drugs only if they are purchased with a prescription. This new rule does not apply to reimbursements for the cost of insulin, which will continue to be permitted, even if purchased without a prescription.

So the question would be, would vitamins and supplements be considered “medicine or drugs”. According to the FDA, they are not. There would be exceptions, and they are:

Supplements – The cost of supplements taken for general well-being are not reimbursable. However, the cost of supplements taken to alleviate a specific medical condition is reimbursable. Physician’s diagnosis letter required.

Vitamins – Daily multivitamins taken for general well-being are not reimbursable. Vitamins taken as treatment for a specific medical condition diagnosed by a physician are reimbursable when accompanied by a physician’s diagnosis letter and a prescription.
Massage – Fees paid for massages are not reimbursable unless to treat a physical defect or illness. Physician’s diagnosis letter required.

A chiropractor is defined under federal law as a physician. So a script would not be needed per se, but a letter of diagnosis with the prescripted supplement would. It will vary based on the patient, case and condition. Sorry this is a longer answer than your question, but I had to look up the info and put it together for you. I have also attached an article that explains the difference between plans, how to use them for chiropractic care, and how to use them for prepay plans.

I hope that clarifies the situation. Let me know if you have any questions.

thanks,

Dave

Wisconsin Chiropractic Board of Examiners Can’t Decide On What to Test Doctors On

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Dateline: March 17, 2011

Happy St. Patrick’s Day and another Wisconsin Chiropractic Board of Examiner’s meeting in Madison.

The WCEB is moving forward on their plans for a live patient, six-hour state practical exam to “improve the quality of chiropractors in the State” (or to limit the number of chiropractors in the State, depending on whom you talk to).

The Department of Regulation and Licensing (DRL) is still concerned that the exam will lack validity and that the financial aspects of administering such an exam have not been adequately confronted.  Since the exam must be “budget-neutral”, the State exam should run in the thousands of dollars for each applicant.

The public in attendance seemed frustrated, especially one DC who broke down as she has moved to Wisconsin but can’t take the board. There is still no exam scheduled for this year, but a promise that there will be one …

Just no promise on what it will be or when it will happen.

Timely Filing of Insurance Claims

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We recently received an inquiry regarding the timely filing of insurance claims and where the responsibility of a denied claim lies.  As many offices may be faced with this similar situation, we would like to share this helpful information with you.  Names have been changed to protect the innocent.

Situation/Question presented:
Situation is we have a patient who was seen two times in our office for a PI $395.  Our policy is to bill the auto med pay portion of the patient’s auto policy. So we billed their auto insurance.  Two months later his wife asked us to bill their health insurance,  so we did .  Months later the bill still was not paid by either insurance  so we resubmitted to the health and it was denied for timely filing saying they did not receive our initial billing.  So before billing the patient I called the auto insurance to see if we could seek payment from them. I was at that point informed they settled with the patient like 8 months ago. they would not tell me the amount but did confirm they had all our claims on file.  I then put together a letter to the patient along with a bill for the full amount.  The patient recently called me disputing this bill saying that in the state of WI  there is a law about collateral source of which states she is allowed to collect from both ins companies and that because of that she is not responsible for the bill.  She said their health insurance  told her because we did not send the bill in time that she is not responsible for it.  She basically is refusing to pay and is threatening us hearing from her attorney if we pursue her.

The way I see it is even if there is a collateral source it doesn’t have anything to do with us. She tried to collect from both parties and it didn’t work out so now she is mad she isn’t profiting from her injuries if she ends up paying us.  As far as her health telling her she isn’t resp. because we didn’t send it in on time. I don’t think they can say that. Isn’t she still responsible no matter what? I have two different lien forms signed by the patient.  I don’t believe we are doing anything that an attorney would even bat an eye at.  We are talking about two visits totaling $395, is it worth it???
I’m just confused on how to move forward with this and wanted to get a second opinion  on this matter before I do so.

Frustrating Billing Clerk
Sample Chiropractic Clinic

Dave’s Response
You are correct. The patient is personally responsible for the bill. Her auto medpay was primary and should have been billed first (which you did). You should have received a denial from them (not sure why you did not, but you can request one) and that should have been forwarded to the health insurance  for any “timely filing” concern.

I have attached an article on disputing the health insurance timely filing claim.  Article
Her attorney (if he or she is ethical) will tell her the same thing, that she is responsible for the bill for services rendered.
So you can do a few things here: rebill to health insurance (disputing the timely filing denial) and balance bill the patient for her portion (deduct/copay/coinsurance) or just send the patient to collections.

I would try the nice approach first and rebill to the health insurance . Make sure you document your collection efforts because I’m sure she will dispute the collection agency.
Thanks, Dave

Medicare, Chiropractic, and Computer Generated Notes

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Is Your Office Looking Into Computer-Generated SOAP Notes? Read This FIRST before you invest your cash!

Thinking that your documentation could use an upgrade? You are probably right, but before you invest in a software generated note system, know that Medicare frowns on most such programs and they could actually hurt you in an audit.

As we have been saying for years, there is no good shortcut out there for doing documentation. You have to follow Medicare’s guidelines and just because your software generates a half page typed SOAP, you may still be missing the mark.

According to ChiroCode Institutes recent alert:

Medicare carrier Noridian Administrative Services recently updated and reprinted a notice on Chiropractic Software-Generated Documentation. Apparently, the piece was generated because Noridian has seen an increase in the use of software-generated documentation for chiropractic services.  Here are a few key areas where software can begin to go wrong (according to Noridian):

– In general, most computerized documentation fails to provide individualized information necessary for reimbursement.

– Software-generated documentation is commonly identical to the letter, comma and space for different patients, with only minor word changes; therefore, it does not reflect medical necessity.  Services supported by repetitive entries lacking encounter specific information will be denied.

– Software-generated documentation often repeats the same phrases and sentences by simply rearranging the words to make it appear as if new information is being disseminated, but when compared to prior days notes, reflects the same or similar concepts.

You can read the whole article here: https://www.noridianmedicare.com/provider/updates/docs/chiropractic_software.pdf%3f. The article contains some humorous (at least to me) examples of  how the software, while randomizing text, generates almost identical SOAPs for different patients on different days.

Getting a Medicare CERT audit? Don’t send in your records without calling us first. See our website for more information on our exclusive Medicare Pre-Audit Documentation Review. LINK

Chiropractors – If You Get a Medicare Audit, Do You Know What to Do Next?

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Are You Prepared?

If You Get a Medicare Audit,
Do You Know What to Do Next?

If you haven’t already heard, CMS Medicare has launched a massive audit project aimed at chiropractic offices around the country. Executive Order #13520 “Reducing Improper Payments and Eliminating Waste in Federal Programs” has unleashed a random attack of chiropractors aimed at recovering an estimated $174,100,000 in over payments.

Medicare has hired two companies to start auditing chiropractors. There is no way to know if you will get a request for an audit, but I can tell you this from being on the road: very, very few clinics will pass a Medicare audit based on the documentation that I have seen.

That’s not to say you aren’t providing proper, necessary care. Far from that. The Medicare documentation requirements for the physician’s signature alone are three pages long.

So What Should You Do?

PM&A is prepared to help you. We have had 25 years of experience with Medicare audits and appeals. If you get a request for an audit, DON’T freak out. Do this instead:

  • Do not ignore it! You have 30 days to respond.
  • Do not let your staff photocopy and send the records out blindly!
  • Call our office immediately and request our special MPDR Program: MEDICARE PRE-AUDIT DOCUMENTATION REVIEW

We will come to your office & go through any requested records with a fine-tooth comb to assist you in ensuring that you have complete documentation for all services rendered, that each date of service is properly documented, that all PART forms are complete, and that active care modifiers have been properly used.

We will go over each entry in the chart with the treating doctor to ensure that every requirement of Medicare documentation is met for the service you rendered. If addendums need to be made, we’ll ensure that the addendums meet or exceed Medicare requirements.

We will also draft a follow up and Medicare Compliance Plan for your office for any areas that need to be corrected so that you can avoid potentially devastating pre-payment future audits or fraud charges.

We have successful fought AND WON on numerous Medicare audits. No other chiropractic management company can say that. A bad Medicare audit can cost well over $100,000 and thousands of staff hours – and more importantly, hurts your patients and their right to chiropractic coverage.

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Medicare Audit Emergency Response Number:     920.459.8500


The MPDR is available to chiropractors in WI, MN, IL, IN, & ND only. This is an emergency response program and slots will be limited to PM&A clients first, then first come. Do NOT send records without calling us first.

The MPDR program covers up to two full days (20 hours) in your office, plus limited follow up. The cost is $4,800 prepaid. PM&A management clients can receive a 20% discount if they are active and current members.

Call for terms and conditions for this service. 920.459.8500

Medicare and Wellness Pricing

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“A client recently asked us ‘What can I charge Medicare patients for wellness care?”  The answer, as is often the case with insurance, is ‘it depends’. There are several factors that must be considered and a few Medicare regulations that have to be reviewed”

Medicare has covered and non-covered services, as you know.

Non-covered services for chiropractic are easy. Exams, x-rays, extremity adjustments (98943), and therapies are all non-covered services and you may charge the patient whatever your fee is or whatever you have worked out. (WPS Medicare Fraud & Abuse Manual, pages 18-19; Sect 1862(a)(1), Waiver of Liability). Any of these services may be billed with a –GY modifier (indicating they are billed for denial purposes only), but they will be denied regardless (http://www.medicarenhic.com/providers/pubs/Chiropractic%20Billing%20Guide.pdf , page 21-22).

Non-covered services are never paid by Medicare. These services are not considered a benefit of the Medicare program. Because of this, there are no restrictions on what you may charge for these services or what a supplemental insurer may pay (ibid). You do not even need to bill them to Medicare except that you may want them to be denied or to be forwarded to a secondary.

Covered services for chiropractic included spinal adjustments (98940-2) when billed for a covered diagnosis (L30328, http://www.wpsmedicare.com/part_b/policy/active/local/_files/l30328_chiro001.pdf ). A covered service can be paid or can be denied as not medically necessary.

If you are a participating provider, and you bill an adjustment (98940-2) with the correct diagnosis and with the –AT modifier, it will generally be paid by Medicare at 80% of the par fee amount. The fee schedule is published annually (http://www.wpsmedicare.com/part_b/fees/physician_fee_schedule/) and is mailed to you on a disk near the end of every year.

If a covered service (98940-2 -AT) is paid, no problem.

If a covered service is denied as not medically necessary, AND you have notified the patient in advance that Medicare may deny the claim (with your ABN form), then you may collect from the patient.

If you have had the patient sign the ABN, and you are doing an adjustment for an acute or active problem as defined above, then you are billing with the 9894x – AT – GA code and modifiers to indicate it was acute care and that the patient signed the ABN (L30328),
(http://www.chirobase.org/19Insurance/CR3449.pdf page 3, http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3449.pdf ).

If you are doing a maintenance or wellness adjustment, and you have had the patient sign the ABN form, you are billing without the –AT modifier but with the –GA modifier (9894x – GA) indicating you are billing a covered service and notified the patient in advance that Medicare will deny the claim. You must still bill Medicare for the service, as it is a covered service (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0749.pdf , page 4, point#6).

If you are doing a maintenance or wellness adjustment or if you are doing services that are not medically necessary (98940-2), and Medicare denies the claim, AND you did NOT have the patient sign the ABN form, the patient should not be billed for the claim, not even for the deductible or co-insurance (Sect 1862(a)(1), Waiver of Liability). The secondary may or may not pay the claim and Medicare does not have any problem or jurisdiction if the secondary or supplemental insurance pays the claim.

Now, hopefully that is all clear. If not, you can go to the references I hyperlinked for further clarification. I always suggest you go directly to the sources on these.

So the simple question is, IF you bill for the adjustment (98940-2) without the –AT modifier, but with the –GA modifier, indicating it is maintenance care and you notified the patient in advance, what can you charge?

Here is what Medicare states:

“The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare. However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare.”

“If an item or service is one that Medicare may cover in some circumstances but not in others, a non-opt-out physician/practitioner, or other supplier, must still submit a claim to Medicare. However, the physician, practitioner or other supplier may choose to provide the beneficiary, prior to the rendering of the item or service, an Advance Beneficiary Notice (ABN) as described in the Medicare Claims Processing Manual Chapter 30. (Also see §40.24 for a description of the difference between an ABN and a private contract.) An ABN notifies the beneficiary that Medicare is likely to deny the claim and that if Medicare does deny the claim, the beneficiary will be liable for the full cost of the services. Where a valid ABN is given, subsequent denial of the claim relieves the non-opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.”

(http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf , Medicare Benefits Policy Manual)

Read the whole section. I have underlined the key point. Medicare does not reprice your normal fees in this case and you are free to charge the patient accordingly.

I know that was a long way around to the answer, but this was not just a yes or no question, as you have to understand Medicare and the factors that are involved.

Dave

Meeting Family Deductibles

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Reply

This article was sent in to us by one of our clients. We felt it was a great suggestion and thought it might help your office when faced with the same situation.

“I just wanted to pass something on that may benefit your other offices.  If we have families that we treat where only two or three of them need to meet their deductibles, we choose the family members that are incurring the most charges and send those in right away.  The other family members we hold the charges until the family deductible is met.

“For instance, we have a family of about 8 people that we are treating that have to meet two deductibles to make their family deductible.  We are only sending CMS-1500 forms on two of those patients until the deductible is met, then we will submit all the bills from the other family members so that we don’t have bits and pieces being eaten out of everyone’s claims unnecessarily”

Filing in this manner, simplifies the collection of the patients out-of-pocket at the front desk, reduces the number of claims affected by the deductibles and overall increases the efficiency of the accounting for these patients.

Thanks Laura D from Family Chiropractic

Online Verification and Claims Follow up Websites for Chiropractic Reimbursement

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Individual sites. You will need to enroll with each, they are free, and they provide accurate and up-to-date information. Each site is a little different, and some are easier to navigate than others.

Medicare (CSNAP) – CMS Secure Net Access Portal
http://www.wpsmedicare.com/part_b/selfservice/csnap.shtml or go here:

http://www.wpsmedicare.com/
and go to the C-SNAP button in the blue bar.

Medicaid – to request Portal access
https://www.forwardhealth.wi.gov/WIPortal/Account/Request%20Portal%20Access/tabid/117/Default.aspx

The following are all links that you should be able to cut and paste into your browser. These are for the login pages that Shelly at our office uses and may not be the page you need to register to login. There should be information on each site on how to register or sign-up if you are not registered.

Aetna
https://enroll.navimedix.com/enrollment/shared/office-search

BC/BS Anthem
http://www.anthem.com/home-providers.html

Cigna
http://www.cigna.com/health/provider/

Secure Health
https://secure.healthx.com/v2App/public/login.aspx

UMR – United Medicare Resources (formerly Fiserv)
https://provider-fhs.umr.com/portal

Humana
http://www.humana.com/ (click on provider button)

Insurance Administrators of America
https://www.iaatpa.com/IAATPA/ProviderServices/Secure/Providers/

MACS
http://www.macschiro.com/ (click on customer logon)

Prairie State
http://www.prairieontheweb.com/prairie/index.htm (click on login/register)

Sisco Benefit Information Systems
https://benefits.cb-sisco.com/

United Health (UHC)
https://www.unitedhealthcareonline.com/b2c/index.jsp

Principal
http://secure05.principal.com/signon/initial/

One-stop services (for verification & claims). This site charges per month, reviews from clients has not been real positive. They are a division on Web MD.

http://www.emdeon.com/

To subscribe to the Medicare email newsletter, so to this site and enter your email address. You will get up-to-the-minute information on Medicare changes. The only drawback is that it is not specific to chiropractic.

https://corp-ws.wpsic.com/apps/commercial/unauth/medicareListservUserWelcomeLoadAction.do

The Centers for Medicare & Medicaid Services (CMS) has implemented an Internet-based Medicare provider enrollment process, known as Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To enroll in Medicare or make changes to your Medicare enrollment, you can now accomplish this online faster and easier. Go here for details and to start the process:

http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp#TopOfPage

Please note: these links were all working and accessible as of June 22, 2009. Some links may have changed.

David Michel &  Shelly Hinz

Please add any updates or extra info you may have that others might find useful. Thanks – Ed