Author Archives: Lisa Barnett

ASK LISA: The Vital Importance of the Post Report & Patient Financial Consultation

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Greetings,

In our last two webinars, we discussed the importance of patient financial consultations.

Let’s delve into why they are so important to your bottom line and how you can set them up for success.

First, changes to insurance coverage and managed care have created an environment where third-party reviewers sometimes have more say in your patient’s length of care than you do.

Second, it is important to note that the financial consultation is a part of the overall Post Report. To be successful, all steps below should be reviewed and completed with each patient, whether they are new or re-activating their care. Why a post report?

The purpose of the post report is for the staff to fully address with the patient any obstacles to the patient getting the care they need and to set the patient up for their schedule of care. This includes setting up multiple appointment schedules, emphasizing the importance of staying on the schedule of care, discussing missed appointments, discussing any needed financial arrangements, going over how to check in at future visits, establishing where the patient should turn with questions or problems, and reassuring the patient in their decision to follow through with care.

Before you meet with the patient for the financial consultation, you also have to have a clear understanding of what you want to accomplish with your financial plans for patients. Your plans need to line up with the goals you have in your office and you need to individualize the plans. Do you want a high percentage of cash, wellness patients? An insurance-based family practice? PI or Work Comp acute care rehab practice? Is the patient undergoing a financial hardship? Each has a different set of criteria for tailoring patient financial agreements.

As these become more common, you can increase your patient retention and compliance by offering more OPTIONS for patient payments. Yes, this requires more work and more follow up, but adjusting to changing business practices in the world often require changing your internal procedures and policies. Adapt and offer ways to make care affordable, then promote these options so that patients see there is a way for them to get the care they need at a price they can afford.

Our Motto: Financial Plans are Liberal; Collections Policies Are Not.

This doesn’t mean reducing your fees or giving away services. On the contrary. For example, a new car costs many thousands more than your treatment plan, but auto dealers are adept at showing the customer ways they can drive that car home today.

Standardizing these procedures will ensure that your patients feel well taken care of at the office at all times.

Questions? We can help.

Click HERE for a sample care plan and financial plan template. [LINK]

Insurance Webinar Sneak Peak

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Hello! Happy October 3rd and Happy Chiropractic Health Month!

table of apples with fall scenery behind

Dave and I would like to invite you to our upcoming insurance webinar on Thursday, October 24, 2024, at 12:00 Central Time. The webinar is Free.

Keep reading for a sneak-peek!

What you can expect from this one-hour presentation:

I. Review of the Revenue Cycle

  • Patient Prospect Call, New Appt. Scheduled, Day 1 Intake
  • Eligibility & Benefits Verification & Patient Financial Consultation
  • Clinical Procedures
  • Submit Clean Claim
  • Receive & Post Payment
  • Insurance denials follow-up
  • A/R follow-up
  • Statistical Reporting

II. Update on UHC and Humana Pre-authorization Requirements for Chiro Services

III.   Update on Wisconsin Physician Service (WPS) & GA modifier usage

IV. Is participation in a particular commercial plan worth your investment?Best reports to run to monitor if your investment is paying off

V. Transitioning to Patient Self-Pay: Things to Consider:

  • Medicare enrollment and Part C participation
  • Medicaid enrollment
  • Do You have resources to conduct thorough financial consultations?
  • Collecting up front, prepays, statements

VI. PI & WC workflow from intake to receiving final payment

VII.   Q&A

This webinar will be particularly beneficial for your billing staff.

Please register below, and we will email you the link to the webinar on October 22nd.

Sincerely,

Lisa and Dave

Register Now

Managing Your Coordination of Benefits

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insurance benefits

YOUR GUIDE TO COORDINATION OF BENEFITS AND WHO PAYS FIRST

Having issues with getting reimbursed due to reimbursement disputes between payer groups? Wondering who to bill first?

This question comes up a lot in the field, which tells me, dear reader, that you may be experiencing frequent circumstances in which your Medicare beneficiary patients fall into one or more of these categories:

  • The patient is not working and is 65 and older and carries retirement insurance
  • The patient has been in an accident resulting in personal injury
  • The patient carries a straight Medicare policy with a secondary insurance policy
  • The patient carries a straight Medicare policy with a supplemental insurance policy
  • The patient has been injured at work
  • The patient or patient’s spouse is working and carries group health insurance

In each of the above situations, Coordination of Benefits kicks in, which is the theme of our September article.

According to eHealth, Coordination of Benefits by definition is: “When a person is covered by two health plans, coordination of benefits is the process the insurance companies [payers] use to decide which plan will pay first for covered medical services and what the second plan will pay after the first plan has paid. Coordination of Benefits prevents duplicate payments for the same service on the same date of service, and helps keeps the cost to the patient affordable.”

Let’s look at each of the above circumstances, with resolution for proper claims processing and reimbursement according to the Centers for Medicare and Medicaid Services:

1.)  The patient is not working and is 65 and older:
Medicare Pays First if the patient has Retiree health coverage and is not
working

2.) The patient has been in an accident resulting in personal injury
The patient’s no-fault insurance or liability insurance pays first and Medicare
pays second for services related to the accident or injury. *

3.)The patient carries a straight Medicare policy with a secondary insurance policy
Medicare is billed first and will forward their remittance to the secondary payer if the services are billed with AT (Active Treatment) modifier.

They may or maynot forward to the secondary if the services are billed with a GA modifier (indicating service was a maintenance adjustment), and will not forward if a GZ modifier is billed (indicating a maintenance adjustment but no signed
Advanced Beneficiary Notice (ABN) is on file), since you cannot bill the patient
for a maintenance adjustment without an ABN.

You may need to file the secondary claim for adjudication on the GA adjustment directly to the secondary payer.

==============================================
Do you have questions or need help with:
insurance audits
credentialing new providers
debugging complex insurance issues
customizing billing systems to improve collections,
practice appraisals, and more.
Ask Lisa
Call Lisa: (920) 334-4561 (mobile)
https://pmaworks.com/lisa-barnett/

============================================

4) The patient carries a straight Medicare policy with a supplemental insurance policy
The same applies as with a secondary policy: Medicare is billed first and will
forward their remittance to the secondary payer if the services are billed with
AT (Active Treatment) modifier.

They may or may not forward to the secondary if the services are billed with a GA modifier (indicating service was a maintenance adjustment), and will not forward if a GZ modifier is billed (indicating a maintenance adjustment but no signed Advanced Beneficiary Notice (ABN) is on file), since you cannot bill the patient for a maintenance adjustment without an ABN.

You may need to file the secondary claim for adjudication on the GA adjustment directly to the secondary payer.

5) The patient has been injured at work
Workers’ compensation pays first for items or services related to the workers’
compensation claim. However, Medicare may make a conditional payment if the
workers’ compensation insurance company denies reimbursement. In this case
the patient is financially responsible but Medicare may pay pending the
insurance company’s review of your claim.

6) The patient and/or patient’s spouse is working and carries group health insurance

    • Medicare pays first in both circumstances if the Employer has fewer than 20 Employees.
    • The group health carrier pays first in both circumstances if the Employer has greater than 20 Employees
    • If the patient has a disability and that patient or spouse is currently employed at an Employer with 100 or more employees, the group health plan pays first
    • If the patient has a disability and that patient or spouse is currently employed at an Employer with less than 100 employees, Medicare pays first

What about in non-Medicare situations where there is a minor child listed as a dependent on dual-spouse or parent policies?
The “birthday rule” is commonly applied for children covered by two employer group health plans. In this situation, the plan covering the parent whose birthday falls first in the year will pay primary on the children; the other parent’s plan becomes the secondary payer.

I hope that this gives you guidance as you navigate through the payer world of coordination of benefits. Have further questions? We can help. Reach out:
lisa@pmaworks.com
920-334-4561

For more info on insurance:

*The exception would be if the case is being handled by attorney representation and a settlement is forthcoming. You may bill the liability carrier and seek renumeration, in which case the patient is responsible for repaying the carrier (or Medicare) for services rendered at your office, after receiving settlement. You may bill the patient for their care up front, in which case they would need to wait for their settlement monies.

References:
1) https://www.medicare.gov/health-drug-plans/coordination/who-pays-first
2) https://www.medicare.gov/publications/11546-Medicare-Coordination-of-Benefits-Getting-Started.pdf
3) https://www.ehealthinsurance.com/resources/individual-and-family/coordination-of-benefits

Revenue Cycle Management (RCM)

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Revenue Cycle Management (RCM)

Two weeks ago we hosted a webinar, How to make insurance work for your office using six components. Since then, there has been interest in learning more about revenue cycle management or RCM. You asked, and here it is delivered.

According to TechTarget*, revenue cycle management is the financial process facilities use to manage the administrative and clinical functions associated with claims processing, payment, and revenue generation. The below diagram will give you a visual. The diagram consists of eight elements, listed here:

  1. Prospective patient calls inquiring about services, and making appointment. This is where your revenue cycle begins. Proper intake sets the stage for future revenues.
  2. Insurance eligibility and benefits verification, is critical for you and the patient to determine best estimates.
  3. Clinicals (doctor treatment(s); diagnoses; and entering charges which can be done by doctor or staff, depending on your office procedures.
  4. Clean Claims submission: Mistakes can happen here, but once you are aware of what needs to be done to create a clean claim, you’ll know what to watch for when you review your claims batches prior to sending.
  5. Payment Receipt or denial from remittances, & Payment Posting
  6. Insurance follow-ups on denials/records requests
  7. A/R Follow Ups
  8. Statistical Reporting (we recommend running: Daily Collections; and then monthly/quarterly/annually running stats on New Patients, Patient Visits, Services-Charges, and Collections.

Revenue Cycle Management (RCM) Diagram

The important thing here is to be consistent, meaning every step and each element of the flow must align with the goals and mission of the clinic. For example, a pediatric/wellness practice will have different polices each step of the way for RCM than a sports medicine clinic would. If you are having issues, you need to examine which step in your RCM is bottlenecked, or which step is not in alignment.

Ed’s book, The Goal Driven Business, will help you ground your practice goals and develop and maintain the consistency needed to keep your goals in alignment with the cycle.

Oh, and if you are leaning towards planning for less insurance participation, watch for details on our next upcoming class, Converting to a Patient Self-Pay Model — Preparing for Your Future Practice.

Happy Fourth of July!

Lisa

PS: Download the RCM Diagram

References:
*https://www.techtarget.com/searchhealthit/definition/revenue-cycle-management-RCM

UPDATE: Change Healthcare Cyber Attack

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Lisa recently had a phone conversation with United Healthcare for an update on the Change Healthcare Cyber Attack Update Regarding United Healthcare Payments & Remittances.  UHC advises that they are close to a resolution on getting all of the clinic remittances available on the provider clearinghouses, and troubleshooting improper denials.

For general inquires regarding payments and posting, clinics can email  client_assistance@optum.com

Ask Lisa: There’s Good News and There’s Bad News When It Comes To Insurance Networks

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picture of a woman There’s an old joke in credentialing providers. “The good news is you’re now in-network! The Bad news? You’re now in-network.”

Should you be “in-network” with a payer group, or out? It’s a tough choice and not a one-size-fits-all. So what do you do? First, ignore consultants that insist you must be or must NOT be an in-network provider.

Next, determine which companies you are in network with and assess. Do you have a contract? What are your provider obligations? Are you getting reimbursed what the contract’s fee schedule says it will reimburse? Are you currently enrolled in Medicare, and are you a participating or non-participating provider. Are you also currently enrolled as a provider in your state’s Medicaid program?

Make sure you have a profile set up with the national Council for Affordable Quality Healthcare (CAQH) universal provider database that the information is current, and re-attested quarterly. There is no charge to create and maintain your profile in this credentialing database.

Third, audit your patient demographic. Run a report in your practice management software. What percentage of your reimbursement is coming from insurance? What percentage is coming directly from patients? Which payers are you mainly seeing patients from? Are you finding that patients are requesting you be in network with a certain company? Who are the main employers in your area insured with? Are you enrolled as a provider with the Veteran’s Administration in your area?

Fourth, develop a spreadsheet called “Insurance Networks” to help you and your insurance department keep the information organized and up to date.

Once you have a grasp on the above, you’re ready to determine if you need to pursue network participation with additional companies. Treating this like a sales or business venture, you’ll want to have insurance companies coming to you and requesting you be in their network. Remember, it is to their benefit and their obligation to keep their paying policyholders happy. Patients should feel free to call their insurer requesting you be on their plan. Patients have done this, and outcomes have been successful. Why? Because the worst phone call an insurance company can receive is from an upset policyholder who can’t afford to see their favorite doctor who is helping them (that’s you!) because the doctor is not on the plan.

Additional items to consider prior to enrolling in a plan include:, What is the reimbursement rate? What percentage of the approved charges are taken out for contract discounts? Is there a fee to join? What are your provider obligations? Do they want you to participate in their workers compensation, PI programs? (In our experience, opting in to the WC and PI products means no steerage to you, and cut reimbursements). Are there pre-authorizations required prior to care? Is there a visit limit? What is the initial credentialing and re-credentialing process?

Now, you are on all the plans that are making your pocketbook and your patient happy. What do you need to do to maintain your in-network status? You will need to notify a payer with updated clinic information anytime there is a change in information you submitted at enrollment. This includes phone number change, address change, and adding a new provider to the office.

You will also need to ensure you track re-credentialing timeframes for each insurance company. Typically, the recredentialing process for commercial payers is every three years, but since your enrollments with each payer fall on different dates, your re-credentialing due dates will vary. Your Medicare re-credentialing is every five years. Re-validation with Medicaid programs is typically every three to five years, depending on your state’s standards. For example, it is every three years in WI and every five years in MI.

Many of the larger commercial payers such as Blue Cross, Humana, United Healthcare/Optum Physical Health, use CAQH to approve your re-credentialing. Those who do not will send a written communication via mail or email letting you know your recredentialing is coming due and will include the applications and instructions. Make sure to track these dates in your insurance spreadsheet.

We’ve just touched the surface of network plans and credentialing. PM&A can provide specialized and unique advice on making the choice of which networks to join, which to be out of network, and which to run away from!

Email me for assistance with how these processes work for your practice. You may reach me at lisa@pmaworks.com
Increasing your collections through better billing and documentation

Ask Lisa: Payer Notes Request: Now What Do I Do?

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stack of medicare insurance paperwork

picture of a womanWith the increase in notes requested from third party payers, more recently Medicare secondary plans, it is good time to review the process once you receive a request.

First, do not ignore the notes request. You can call the payer acknowledging receipt of their request, or simply print or export the SOAP notes from your practice management program and send them to the payer. It is also highly recommended to include the initial patient intake form, or New Episode patient form, exam form(s), and care plan schedule including treatment goals which can simply be specific ADL functions pre-injury.

I also recommend looking to see what the most current Onset date is in your patient profile. Many recurring notes requests are due to the onset date going back two years and more. If this is the case, the patient is due for a re-exam and more than likely a new set of diagnosis codes, and you can include this information in your response to the payer.

If you need a review on what exactly to include in a SOAP note, click on this link HERE to access the checklist that complies with Medicare documentation requirements.

I use this checklist when I conduct onsite documentation reviews.

Questions? Need help with a documentation audit? Ask Lisa – I can help!

920-334-4561

lisa@pmaworks.com

Ask Lisa – Introduction

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Lisa Barnett practice appraisals credentialing and

Lisa J. Barnett

HI!

I’m Lisa with Petty, Michel and Associates.

I’ve been with this wonderful company for nine years and have worked in the chiropractic profession for 17 years.

Do you need help with:

• credentialing new providers and/or your tax ID?
• debugging complex insurance issues?
• documentation/insurance audits?
• practice appraisal?

Would you like these projects completed without you or your team spending time doing it on your own?

Let me do it for you!

Contact me. Because some practice issues shouldn’t wait.

lisa@pmaworks.com

920-334-4561

Find out more about me here

== == ==

“I Give PMA Two Thumbs Up!
Lisa was incredibly helpful and created huge value and peace of mind when she came face to face to my clinic and looked over everything. There are core competencies when it comes to dealing with Medicare and Petty Michel and Associates knows the process and what Medicare will be looking for if you get a notes request or an audit request.

PMA proved to be a huge value and I am thrilled they were able to help my clinic become compliant, which makes seeing Medicare and Medicaid patients more enjoyable and less worrisome. I give PMA two thumbs up.
—
Matt Kingston D.C.
Madison Chiropractic Solutions

REMINDER: New ABN form mandatory starting June 30, 2023

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petty, michel, medicare, goal, driven, insurance, abn

picture of a woman

Just a reminder that the NEW ABN form released earlier this year is mandatory beginning June 30th, 2023.  To clarify this only pertains to medicare patients that begin care after June 30th, 2023.

For your convenience we have included in this blog the forms in English and Spanish and helpful information for implementing the new form.

New ABN Form and Implementation Instructions

ABNEnglish_01312026_508 English version of the ABN effective June 30th, 2023

ABNSpanish_01312026_508 Spanish version of the ABN effective June 30th, 2023

2023-04-20-ABN-Form-Instructions:

2023-04-20-NEW-MEDICARE-ABN– Helpful tips from Lisa for the use of the new Medicare ABN effective 6/30/2023

Script-for-ABN-form– Script for explaining the form to the patient

As always, Lisa is available if you need further assistance with anything Medicare related.  .

Medicare Providers Re-validation Update Announced

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UPDATED FROM JANUARY 24th, 2022

Dear Chiropractors, Office Managers, and Insurance Personnel:

“The Center for Medicare & Medicaid Services is continuing to populate providers’ re-validation due dates from a ‘TBD’ date to an actual due date.

Per CMS (data.cms.gov):

  1. The re-validation data was last refreshed on August 01, 2022.
  2. ‘Adjusted’ Re-validation Due Dates for October 2022 have been added.
  3. The next data refresh is tentatively scheduled for September 1, 2022.
  4. Affiliations now include reassignments as well as Physician Assistant(PA) employment relationships.”

https://data.cms.gov/tools/medicare-revalidation-list

=====

January 24th, 2022

As you may be aware, the Center for Medicare and Medicaid (CMS) made an accommodation during the pandemic regarding your doctor re-validation due date with Medicare. As such, CMS will be adjusting doctors’ re-validation due dates in phases starting this quarter. The Medicare Enrollment online tool, PECOS, has shared information on their homepage that enrollment re-validation has resumed in a phased approach for active providers.

What this means for you: It is critical that you check your re-validation due date and re-validate your Medicare enrollment prior to your due date. If you don’t re-validate, claims will most likely deny when their software program catches a mismatch to enrollment due dates, and you may lose your billing privileges. If you reassign your benefits to your group/Type 2 NPI, you will need to re-validate the group enrollment as well. The re-validation requirement holds regardless of if you are a participating or non-participating provider. There is no fee to re-validate.

CMS has stated they will notify providers via email on file, or mail, approximately three to four months prior to their adjusted due date. You can check your re-validation due date here:
https://data.cms.gov/tools/medicare-revalidation-list

Once you open the page, you will see two due date boxes. You may disregard the original due date shown on that page. The box to pay attention to is the “Adjusted Due Date”. If it states TBD, keep checking every couple of weeks to see if that field has been populated to show your adjusted due date.

How do you re-validate? Use online PECOS (the preferred method), linked here: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

Or submit a paper 855i application, found here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855i.pdf

References:
Please see the initial communication here:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

Additional related links:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Revalidations

https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf

Contact us if you have any questions – we’ve got you covered!
(This includes if you can’t get into your PECOS account because it’s been so long, or because of staff changes, or because you forget your password, call us and we can help you.)

Lisa Barnett
920-334-4561
Petty, Michel & Associates

Email: lisa@pmaworks.com, dave@pmaworks.com

“No Surprises Act” effective January 1, 2022

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“Wondering about the new federal ruling to end surprise patient billing?

Though this mainly pertains to hospitals and emergency services, chiropractic  providers are impacted as well.  Click here to see  Medicare’s explanation on the ruling. https://www.cms.gov/nosurprises/consumers/understanding-costs-in-advance

For over 35 years, Petty, Michel and Associates has been at the forefront of educating doctors and staff on utilizing financial consultations and worksheets to estimate out a patient’s out-of-pocket financial responsibility for their care.  If you are interested in how you can obtain our Financial Consultations Toolkit,  please contact Lisa at lisa@pmaworks.com.”

Lisa

Key Updates and Workarounds For the New ICD-10 Codes That Impact Your Office.

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icd-10, key updates for 2022Dear Chiropractors and Staff:

Are you having issues with not getting reimbursed due to the new ICD-10 codes and the deleted low back code? Having difficulty getting reimbursed from Humana and BCBS due to precertification requirements and other crazy denial codes?

Please read below where I provide you three key updates to the ICD-10 Codes and some workarounds that are of interest to your revenue cycle.

UPDATES: ICD-10 code Changes relevant to chiropractic

1. Deleted code: M54.5 low back pain.

2. NEW codes to replace the above deleted code include:
• M54.50 Low back pain, unspecified
• M54.51 Vertebrogenic low back pain
• M54.59 Other low back pain

3. Other Chiropractic-Relevant New codes added:
• M45.A0: Non-radiographic axial spondyloarthritis of unspecified sites in spine
• M45.A1 : Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region
• M45.A2 : Non-radiographic axial spondyloarthritis of cervical region
• M45.A3 : Non-radiographic axial spondyloarthritis of cervicothoracic region
• M45.A4 : Non-radiographic axial spondyloarthritis of thoracic region
• M45.A5 : Non-radiographic axial spondyloarthritis of thoracolumbar region
• M45.A6 : Non-radiographic axial spondyloarthritis of lumbar region
• M45.A7 : Non-radiographic axial spondyloarthritis of lumbosacral region
• M45.A8 : Non-radiographic axial spondyloarthritis of sacral and sacrococcygeal region
• M45.AB : Non-radiographic axial spondyloarthritis of multiple sites in spine

NEW Cough codes:
• R05.1:Acute cough
• R05.2: Subacute cough
• R05.3: Chronic cough
• R05.4: Cough syncope
• R05.8: Other specified cough
• R05.9: Cough, unspecified

WORKAROUNDS
If you have claims to send (hopefully only a few) with DOS prior to October 1, with low back pain diagnoses, what should you do to ensure they do not reject by the clearinghouse and payer for adjudication? Your clearinghouse should, by now, be updated to include accepting claims with the old M54.5 code IF the DOS is prior to 10/1/2021. The commercial payer claims adjudication systems should also be updated now to accept claims prior to 10/1/2021 DOS if you billed with the old M54.5 code. Please make sure to get any outstanding claims with DOS prior to 10/1 submitted as soon as possible, if you have not already. If you only have a few claims going to commercial, you also have the option of sending these on paper instead of through your clearinghouse. Do not do both.

State Medicaid programs and Medicare will still require the use of the M99 codes for billing, so continue using those codes for these claims.

HUMANA is requiring pre-authorizations on all chiropractic therapy codes. The latest news is that starting in January, there will now be three entities that will be doing the pre-authorizations. a. Optum, b. Humana itself, or c. A new vendor, Cohere Health. Humana has advised us that the entity will be selected based on the patient’s policy.

When you verify a patient’s benefits you will need to make sure to ask:
if preauthorization on your therapy/rehab codes is required on the member’s policy,
which entity will be preauthorizing/reviewing,
and the process to follow when requesting services requiring preauthorization.

Not getting paid by BCBS, with crazy denial codes? No one at BCBS to help? You’re not alone. Offices across the country are experiencing this. So what can you do at this point? First, do a claims audit on your BCBS claims. Do you have the GP modifier attached? Is preauthorization on therapies required on the patient’s plan using AIM Specialty Health?

Your other option is to ask the patient to call into BCBS and advise that claims are being denied even though they have been billed out correctly. We do have scripting available to help your patients with the communication. Click here and request more information.

Questions? We’re here to help!

Lisa Barnett
PH: 920-459-8500
Email: lisa@pmaworks.com

“Increasing your collections through better billing and documentation”

New Year = Coding Changes.

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As we leave the crazy year of 2020 and enter a fresh 2021, here is a summary of  Coding changes taking place that impacts your clinic operations and bottom line:

I. CPT Code 99201 is being deleted effective 1/1/2021

A. Documentation for CPT Codes 99202 through 99205 will be required using criteria of Medical Decision Making OR Time element to determine the level of coding.

o Medicare requirements remain the same for medical decision-making criteria using P.A.R.T. (Pain, Asymmetry/misalignment, ROM decrease, Tissue tone changes) OR diagnostic imaging with documented report of objective findings.

B. CPT 99211 (re-exam) is not being deleted but not used very frequently, and some payers do not pay chiros for this code. You may still bill 99211 when a CT licensed in history-taking and exams performs a re-exam.

C. The 2021 treatment plan model will be the same as 2020:

o Number 1 documentation priority Medicare is looking for: Goals (time or distance element, for example ADLs or specific exercise)
o Number 2 element = duration of care (for example 24 visits)
o Number 3 element = frequency of care (Example – 2X/week for 12 weeks)

II. Changes to ICD-10 codes relevant in chiropractic

1. The following codes have been Added:

A. Arthritis of temporomandibular joint

i.   M26.641 right
ii.  M26.642 left
iii. M26.643 bilateral
iv. M26.649 unspecified

B. Arthropathy of temporomandibular joint

i.   M26.651 right
ii.  M26.652 left
iii. M26.653 bilateral
iv. M26.659 unspecified

2. Deleted ICD-10 Codes:

A. M92.50, M92.51, and M92.52 deleted. (Juvenile osteochondrosis). Use M92.8 or M92.9 instead
B. R51 (this headache code deleted). Here are two specific codes added, to use instead:

i. R51.0 Headache with orthostatic component, not elsewhere classified
ii. R51.9 Headache, unspecified

III. Medicare 2021 Reimbursement on covered CMT
Please note a significant reduction in reimbursement across the board for select specialty physicians and surgeons. Here is the chiropractic fee schedule:

Referring back to the exam discussion above, you may want to consider raising your E/M code fees. However, be advised insurances will not reimburse at your full fee, and Medicare as well as most Part C plans as of this writing do not pay for exams performed by Doctors of Chiropractic. These charges are patient responsibility.

Questions? We’re here to help!

Call 920-334-4561 or email lisa@pmaworks.com

Cheers!

~Lisa Barnett
Increasing your collections through better billing and documentation.

References:

New Medicare ABN-effective 1/1/2021

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Medicare has released a new ABN which will be implemented starting January 1, 2021.  There are two versions, an English and Spanish version.  Click the link to download now.

ABN English

ABN Spanish

Remember . . .
The ABN is required for your Medicare patients to sign when:

They transition from Active Treatment to Maintenance or Wellness Care.

The ABN is voluntary when:

It functions as your financial policy, and the patient is still on Active Treatment.

GUIDELINES:

  • Do not have the patient sign an ABN at every visit, per CMS.
  • When the patient presents with a new episode/injury, the current signed ABN on file is nullified.
  • When the patient transitions back to maintenance/wellness, have them sign a new ABN.
  • The signed ABN is good for one year.
  • The patient/guardian should be the one to choose between Option A, B, or C, with the staff. explaining what each option entails. This prevents potential doctor liability down the road, i.e., the patient or guardian states to Medicare that they were forced or pressured into choosing a certain option.
  • Use an AT modifier when billing Medicare for Active Treatment (ABN not required).
  • Use a GA modifier if the patient chose the option on the form to bill Medicare, and an ABN is on file. Then the Medicare remits can be forwarded or are crossed over to the Medicare supplement plan for possible payment.
  • Use a GZ modifier when billing Medicare for maintenance/wellness care but an ABN is not on file. (The most common reason is the clinic got busy and missed having the patient sign it).
  • The ABN is not used with Part C/Medicare Replacement plans. Only use for Medicare Part B plans.
  • You may begin using the new ABN in December. The new one will be required as of 1/1/2021.

Questions? I am here to help! Contact me at lisa@pmaworks.com, or call 920-334-4561

Lisa
“Increasing your collections through better billing and documentation”

Insurance Network Participation and Getting the Best Bangs for Your Buck

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Have you ever . . . Wished there was an easy way to make sense of the array of insurance networks out there? Should I be in? Should I opt out? Here’s a guide for you and your staff to follow to help you decide whether pursuing a specific insurance contract, and staying in, is worth your time and investment:

First, determine which companies you are in network with. Do you have a contract? What are your provider obligations? Are you getting reimbursed what the contract’s fee schedule says it will reimburse? Do you have a profile set up with the national Council for Affordable Quality Healthcare (CAQH) universal provider database and is the information current, and reviewed quarterly? There is no charge to create and maintain your profile in this credentialing database.

Second, make sure you know if you are currently enrolled in Medicare and if you are a participating or non-participating provider. Are you also currently enrolled as a provider in your state’s Medicaid program?

Third, audit your patient demographic. Run a report in your practice management software. What percentage of your reimbursement is coming from insurance? What percentage is coming directly from patients? Which payers are you mainly seeing patients from? Are you finding that patients are requesting you be in network with a certain company? Who are the main employers in your area insured with? Are you enrolled as a provider with the Veteran’s Administration in your area?

Fourth, develop a spreadsheet called “Insurance Networks” to help you and your insurance department keep the information organized and up to date.

Once you have a grasp on the above, you’re ready to determine if you need to pursue network participation with additional companies. Treating this like a sales or business venture, you’ll want to have insurance companies coming to you and requesting you be in their network. Remember, it is to their benefit and their obligation to keep their paying policyholders happy. Patients should feel free to call their insurer requesting you be on their plan. Patients have done this, and outcomes have been successful. Why? Because the worst phone call an insurance company can receive is from an upset policyholder who can’t afford to see their favorite doctor who is helping them (that’s you!) because the doctor is not on the plan.

Things to consider prior to enrolling in a plan include:

  • What is the reimbursement rate?
  • What percentage of the approved charges are taken out for contract discounts?
  • Is there a fee to join?
  • What are your provider obligations?
  • Do they want you to participate in their workers compensation, PI programs? (In our experience, opting in to the WC and PI products means no steerage to you, and cut reimbursements).
  • Are there pre-authorizations required prior to care? Is there a visit limit?
  • What is the initial credentialing and re-credentialing process?

Now, you are on all the plans that are making your pocketbook and your patient happy. What do you need to do to maintain your in-network status? You will need to notify a payer with updated clinic information anytime there is a change in information you submitted at enrollment. This includes phone number change, address change, adding a new provider to the office.

You will also need to make sure you are tracking re-credentialing timeframes for each insurance company. Typically, the recredentialing process for commercial payers is every three years but since your enrollments with each payer fall on different dates, your re-credentialing due dates will vary. Your Medicare re-credentialing is every five years. Re-validation with Medicaid programs is typically every three to five years, depending on your state’s standards. For example, it is every three years in WI and every five years in MI. Many of the larger commercial payers such as Blue Cross, Humana, United Healthcare/Optum Physical Health, use CAQH to approve your re-credentialing. Those who do not will send a written communication via mail or email letting you know your recredentialing is coming due and will include the applications and instructions. Make sure to track these dates in your insurance spreadsheet.

We’ve just touched the surface of network plans and credentialing. Email me for assistance with how these processes work for your practice. You may reach me at lisa@pmaworks.com
Happy Credentialing!

Lisa
“Increasing your collections through better billing and documentation”

Trizetto Moving to the Cloud

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I wanted to pass along the following communication from Trizetto to help you with a smooth transition.

Please share it with your insurance and billing team so they can plan accordingly. Remember, claims will not go, and EOBs will not be accessible during the time-frame of 11:59 p.m. CST on March 14, 2019 until approximately 11:59 p.m. on March 17, 2019.

If you are not a Trizetto/Gateway EDI client, you can disregard the information below.

Sincerely,

Lisa Barnett

“Increasing your collections through better billing and documentation.”

=====================

Important Message from Trizetto Electronic Claims Submitter

RE:  Microsoft Azure® Migration

Dear Valued Client,

In order to ensure the most secure, reliable and highest performing platform for our services, TriZetto Provider Solutions, a Cognizant Company, will migrate data from our St. Louis data storage facility to the Cloud-based Microsoft Azure® platform.

Why Are We Migrating?

A cloud-based data center will align data transport security protocols to industry standards while also providing significantly enhanced information security and opportunities for growth. We believe the benefits of this migration far outweigh the costs, and that our clients will benefit greatly from this transition. Benefits include:

  • Increased speed
  • Consistent, reliable storage capabilities
  • Higher levels of security

How Will Your Organization Be Affected?

The transition of data will have a direct impact on our clients. Because of the migration, clients will experience an extended outage starting at 11:59 p.m. CST on March 14, 2019 until approximately 11:59 p.m. on March 17, 2019. During this time all applications will be inactive and no incoming transactions will be accepted for processing.

TPS is working diligently to ensure a seamless transition. We have chosen to put this project into effect over a weekend to minimize impact to our clients. We apologize for any inconvenience this may cause.

If you have any questions or concerns, please reach out to our customer service team at 800-556-2231 or physiciansupport@cognizant.com. Thank you for your patience and support during this time.

-TriZetto Provider Solutions

Health Account Savings Plans: Assisting Your Patients To Stay on Their Treatment Plan

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Welcome to your best chiropractic year!

Commercial health insurance carriers such as United Health Care and Anthem BCBS can offer their customers, who are also your patients’ employers, two different health account savings options:

  • Health Reimbursement Arrangement
  • Health Savings Account

An employer can also directly offer the benefit of their employees signing up for a Flexible Spending Account.

Let’s dig into each one!

What is a Health Reimbursement Account? (HRA)

A Health Reimbursement Account (HRA) is an account that your patient’s employer funds to help the employee pay for covered healthcare services. The patient cannot put monies into an HRA, as the account is owned by the employer. This includes paying for services (chiropractic office visits) that apply to the patient’s deductible. The patient can begin using their HRA on the first day of the plan year. Since the patient’s employer controls the fund, the employer has the ability to make the rules on when and how the patient can use the money. Additionally, there are coinsurance-only HRA plans available, whereby the patient’s employer will pay only coinsurance amounts.

The patient does not have to pay taxes, state or federal, on HRA monies, so it is a tax savings. The HRA cannot earn interest as it is not a personal bank account.

How do you, Doctor, get paid? Once claims are submitted to the insurer, the insurance carrier will pay, as long as the patient has funds in the account. You will typically, but not always, receive two EOBs/remittances for the same DOS. This is usually due to that first charge going to the patient’s PCP and then getting denied and forwarded to the employer. Referrals from the patient’s PCP to your office is not a requirement tied to an HRA.

There is only one account set up for all covered dependents on a plan. The employee does not report the HRA monies to the IRS.

Takeaways:

  • Get in good standing with your community’s businesses and industries so chiropractic can stay included on their coverage and benefits, and you can get those referrals!
  • Billing Tip: Make sure you are posting to the most recent, newest remittance.

Health Savings Account (HSA)
A Health Savings Account is a savings plan set aside for taxpayers who enroll themselves in a high-deductible health plan. They can be offered by your patient’s employer as an employee benefit, or the patient may elect to sign up independently. The benefit here is that the funds are not subject to tax liability upon deposits. Moreover, if there are monies left in an HSA, they can roll over into the next year. When your patient’s health plan offers this type of plan, they are provided with a debit or credit card to make their eligible health service purchases. Both the patient and their employer can contribute to the fund. The patient must report this account to the IRS when they do their taxes.

Takeaway:

Health Savings Accounts are not owned by the patient’s employer. All taxpayers with high-deductible health plans are eligible and must report this account to the IRS when doing taxes.

Employer-based Flexible Spending Accounts (FSA)
An Flexible Spending Account is a special account the patient puts money into to pay for certain out-of-pocket expenses such as medical related, dependency related, and a limited dental and vision plan. This arrangement also has a tax-free benefit. The list of all eligible expenses can be found on the IRS website at: https://www.irs.gov/newsroom/irs-plan-now-to-use-health-flexible-spending-arrangements-in-2019

The employer owns this account.

A frequently asked question I get is, does an FSA cover massage?
Answer: Yes, it does with the ordering physician (chiropractors included) writing a note of necessity for the massage therapy.

When there are monies left over in the account at the end of the year, the employer has two options they can offer their employees:

  1. The patient can set aside the monies and use it up to two-and-a-half months into the new year, or
  2. The employer can allow the employee to carry over up to $500 from one year to the next.

Takeaway:
There are several eligible out of pocket expenses that an FSA will cover. Click on the IRS link for more information: https://www.irs.gov/newsroom/irs-plan-now-to-use-health-flexible-spending-arrangements-in-2019

SUMMARY
If your patients struggle to keep their appointments due to financial concerns ask them if they have one of these savings accounts that might be able to supplement payment of their care and keep them on their treatment plan.

Oh, one further heads-up to our profession just finding its way down the pipeline . . . you may have or will be receiving a letter from a TriWest Family Alliance group out of Arizona promoting their billing services on behalf of VA offices. This letter is being distributed nationwide. Please note we have researched this, and credentialing and contracting with this group is optional. If you already have a contract with your VA, you may continue treating VA patients as usual. There is no change in their referral of patients to you, or the preauthorization process.

If you have any further questions, don’t hesitate to reach out to either myself or Dave.

Please feel free to forward this article to your insurance department.

Adios for now!
Lisa

“Increasing your collections through better billing and documentation.”

Medicare, Yada, Yada, Yada: Fraud, Waste and Abuse Training.

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OK, I admit it. Medicare is not the most glamourous topic to write about, nor does much of it pertain to our world of the chiropractic profession as we know it. However with that said, I am doing due diligence for you and fulfilling my duty to inform you of the necessary requirements a Covered Entity must follow (that’s us included!) to keep the Office of Inspector General off our backs and to help you take preventive measures so you’re not sending back reimbursement money you earned from providing patient care.

Because . . . based on my observations in the field – and this is a review for those of you who read our PM&A articles and utilize our library- how many of you know, for example, what a Part C Medicare plan is? How many of you know that all Part C providers are required to undergo annual Fraud Waste and Abuse training?

Second example: How many of you are aware that Medicare, starting in April of this year and going into April of 2019, is sending all of their beneficiaries new ID cards in an effort to do away with social security numbers for the sake of safeguarding identification?

So how do my two examples above directly impact you, your practice, and your bottom line?

Let’s circle back to the first example. A Part C Medicare Plan is known as a Medicare Advantage Plan. It oftentimes covers more services than a straight Medicare plan does. HMO/PPOs such as Humana and Blue Cross Blue Shield have developed their own Medicare Advantage Plans and offer them to their policyholders, your patients. A patient who signs up for an Advantage Plan must also be enrolled in Medicare A (hospital), and Medicare B (outpatient provider services). Medicare Part C providers to date have been required to, annually, undergo what is called Fraud, Waste and Abuse Training. Let’s take each of the three words and define them from the Medicare and Medicaid world.

  • Fraud is known intent to deceive in order to collect money from the Medicare program illegitimately.
  • Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of office and/or practice resources.
  • Medicare Abuse includes practices that result in unnecessary costs to the Medicare program such as over or underutilizing services. You are probably familiar with the Quality of Care initiatives such as MIPS/MACRA and the EHR incentives, implemented to help combat abuse. Common types of abuse include:
    • Billing for unnecessary services
    • Overcharging for services or supplies
    • Misusing billing codes (upcoding) to increase reimbursement*

*Downcoding is also a misuse of billing codes. Stop doing it. Although not intended to increase reimbursement it is a red flag to Medicare, and your services will be questioned as to if they were “medically necessary.”

Back to the training . . . I urge you now to complete this training by the end of December. It is intended for doctors and staff. Download the PowerPoint below, read thoroughly and after completion have each staff and doctor sign off to attest, they read through the PowerPoint. The sign-off can be as simple as logging signatures and completion date in a notebook or a spreadsheet. It is not necessary to print out the PowerPoint. Oh, and many insurance contracts require this training as a contract obligation to be part of their network as well. You can access Medicare’s training PowerPoint here: Fraud, Waste and Abuse

Referring back to the second example of new Medicare cards. You can review our previous article and checklist here: New Medicare Beneficiary Indentifiers to be Assigned Your Patients

Your staff should be asking Medicare patients for their new cards, making a copy, and making sure the address in your practice management program matches the address the Social Security office has on file. If there is a mismatch like the patient has moved and not updated their address, you will have problems getting reimbursed. Make sure your Insurance Profiles in your programs have the new Medicare IDs.

Stay tuned for more helpful articles like this. If you have any questions on the above, contact me! I’m here to help.

Lisa Barnett
920-334-4561
lisa@pmaworks.com

And remember . . .
“The Future Will Be Our Results” (Clarence Gonstead, D.C.)