Chiropractic Prepayment Plans in South Dakota? Think Again!

Posted on December 29, 2011 by Dave

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

Posted on November 16, 2011 by Dave

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.

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.
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.)
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.”)
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

Electronic Health Records and Chiropractic

Posted on July 18, 2011 by Edward Petty

There is more and more attention being placed on the topic of Electronic Health Records. For those of you who are not familiar with this subject, you can find basic information on the web sites of CMS (Centers for Medicare and Medicaid Services) and of course, Wikipedia. There are other sources, but reader beware: many have ties to software companies (and their advertising and promotional distributors) that are trying to make a case for buying expensive software now.

Here is a Q&A with Dave Michel and one of our clients regarding this subject which may be helpful in understanding what is going on:

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

Dear Dave,

Dr. H wanted me to e-mail you with some of our questions and concerns. We are hearing a lot of different things the more people we talk to about it. We are hoping that you can shed some light on the situation. Here are some of our questions:

Is the deadline for reimbursement this October 2011? Or do we have until October 2012?
There is no deadline at this point. It is not a requirement and, even if it is, there will be an exemption for small offices (usually less than 10 FTEs).

Is there a checklist of things that need to be completed in order to be compliant? Do we need to have digital x-ray in order to be compliant?
Yes, there is a checklist. If you google CMS EHR Incentive you will find a couple on the CMS website (skip software vendor websites …). Digital x-ray is NOT a requirement.

Is it a tax credit or would we receive a reimbursement check? Will it just cover the EHR software or will it cover equipment upgrades/replacement as well?
Beginning May 2012, you would be possibly eligible for up to $18,000 per year in incentives paid as a check to each provider. The limit would be based on 75% of your prior year’s Medicare reimbursment. IF you are “an eligable provder” and you have demonstrated “meaningful use”.

How much should we expect to spend on this process? And how much will we get reimbursed? Is it a percentage or the exact amount? And is it a guarantee?
Great questions. EHR software for chiros ranges between $2.5 – $27k. Add to that the cost of conversion in your office (thousands) and the reduced efficiency (eg if the new program adds 2-3 minutes to each patient encounter). This is going to be a big process.

Dr. H wants to know “what happens if we don’t become compliant?”.
Nothing. Yet …

Thank you so much for taking the time to answer our questions.
No problem! Bottom line (if you haven’t picked up on this so far …): I am not a fan of any of the EHR programs currently out there. They either add too much time to each patient visit or they produce a SOAP note that would not pass an audit / records review. There is NO guarentee that Big Government is going to be mailing out $44k checks to each provider for doing something that will really not improve the heath care delivery system

Most of what you have seen are from companies marketing their products (seminars, EHR software, etc). There is NO mandatory deadline (yet) to convert to EHR and so far, I have not received confirmation from CMS that chiropractors will receive any money or incentives to convert to EHR. I do have a letter in to CMS to get an official word and will let you know. It does not make sense to me that CMS will give each chiropractor $44,000 to convert to EHRs when the CMS program is going broke. But I will let you know.

For questions about EHR, feel free to contact Dave at Dave@PMAworks.com

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

Posted on April 11, 2011 by Dave

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

Posted on April 11, 2011 by Dave

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.
– – – – – – – – – – – – – – – – – – – – – – – – – — – – – – –

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

Timely Filing of Insurance Claims

Posted on December 24, 2010 by Dave

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

Posted on October 5, 2010 by Dave

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?

Posted on August 30, 2010 by Dave

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.

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

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

Health Care Reform Poster

Posted on August 12, 2010 by Linda

TRUE HEALTHCARE REFORM

Patients regular utilization of
chiropractors as primary care physicians reduces the need for:

Hospitalization by 60.2%
Hospital days by 59%
Pharmaceutical usage by 85%
Outpatient surgeries and procedures by 62%
Overall global health care cost by 50%

This according to a clinical and cost utilization study conducted by an independent physician association done over a 7 year
period and that included doctors of all licenses. J.M.P.T. Vol30, Issue 4, pages 263-269, by Dr. Richard Sarnat, M.D.

For a printable copy of this statement click here: True Healthcare Reform Poster

Last Seminar/Next Seminar

Posted on May 3, 2010 by Linda

We just finished our 10 classes in 1 day seminar in Minneapolis – our “10 in 1.” From what I heard and saw, everyone had a great time. I know we did. And for my money, I think we had some of the best professionals in the country giving presentations – as well as attending!

: Dave Michel at 3Goals Seminar in Minneapolis

In addition to great presentations by Phyllis Frase on chiropractic philosophy and procedures for staff, Dave Michel on insurance, and myself on marketing and practice building, we had two guest doctors.

: Dr Tom Potisk at 3-goals Seminar in Minneapolis

One was Dr. Tom Potisk who went over how he maintained a joyful practice for 25 years in a multi-doctor setting with 2 associate doctors.

: Dr. Shane Walker at 3-goals Seminar in Minneapolis

Then, as a special guest, we were pleased to have Dr. Shane Walker who is the president of the Federation of Straight Chiropractors. He lit the room up with passion, statistics, and purpose and reminded everyone about the power of chiropractic, as well as it’s importance in society today.

So, just a reminder:

Our Milwaukee seminar is coming up soon.

Dave, Phyllis, and myself all have new material covering C.A. training, insurance and reimbursement procedures, and marketing and practice building. Our presentations are all based upon the work we do each week in offices across the country – and what we see working, and not working.

For our Milwaukee seminar, we are especially pleased to have two exceptional doctors giving presentations on Thursday, May 20th. Both are highly qualified and successful doctors that set great examples for excellence in their practice, business, and life.

We will be sending info out on them soon, but you can find out more here.

Hope to see you all in Milwaukee.

Medicare and Wellness Pricing

Posted on January 22, 2010 by Dave

“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

Posted on January 19, 2010 by Dave

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

Posted on July 23, 2009 by Dave

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

Timely Insurance Filing

Posted on March 16, 2009 by Dave

Every insurance company has a time window in which you can submit claims. If you file them later than the allowed time, you will be denied.

For most major insurance companies, including Medicare and Medicaid, the filing limit is one year from the date of service. If you are a contracted or in-network provider, such as for BC/BS or for ACN or HSM, the timely filing limit can be much shorter as specified in your provider agreement. It may be six months or even 90 days.

There should seldom be a time when claims are filed outside the filing limit. The only exceptions might be when you are dealing with a Medicare secondary and were appealing a denial prior to submitting to the secondary, or when an account was sent to work comp, then after much review was denied as not liable and now must be billed to health insurance. In these cases, you can appeal the claims, but you must call the insurance company and see what their appeal rights are. Medicare and Medicaid have specific appeal guidelines in their provider manuals, but other insurance companies vary.

If you actually were outside the timely filing limit, many insurance companies and most provider agreements prohibit you from pursuing the patient for the denied balance. It is also poor consumer relations to make the patient pay for your office’s failure to submit the claim.

Rebills on Claims Filed Timely
A frustrating problem when doing account follow-up is that most insurance companies only hold or “pend” claims in their system for 60 to 90 days. After that, if they are not paid or denied, they are deleted from their computers. A large insurance company may receive over 100,000 claims a day and their systems cannot hold that volume of pending claims. When you call to follow up, they will state, “we have no record in our system of having received that claim.”

Now your only recourse is to rebill the claim. If it is outside their “timely filing”, you will get a denial back. You should and must now appeal the denial. The first thing that you will need is proof that you actually did file the claim within the time window allowed.

Proof of Timely Filing
For paper claims, you can reprint and attach the original claim, however some billing software will put today’s date on the reprinted claim. Ask your software provider to walk you through reprinting a claim with the original date. There is no reason to photocopy all claims just in case you need to prove timely filing. For electronic claims, you should have the claims submittal report from your clearinghouse. These should always be kept (in electronic format) on your computer by date in a folder that is regularly backed-up.

[Sample Appeal Letter for Timely Filing]

Name of Insurance Company
Address (get address for appeals if it exists)

Re: Appeal of Denial for Timely Filing

Patient Name:
Group Number: DOS:
Subscriber No: Reference No.:
(etc – get this information from the denial)

We are appealing the denial of claims for (patient name) and request that these claims be reviewed and paid.

On (original submission date) we submitted claims for services rendered to the above patient. This was well within your timely filing deadline.

The promptly and properly submitted claims were neither paid nor denied by your company. On (date of resubmission) we resubmitted the claims for consideration. On (date of denial) we received a denial of the claims for “timely filing”. Please see the attached EOB from your company.

I have attached copies of the original claims showing the date they were printed. Our office policy is to send all claims on the date they are produced. The printed date is the date of submission and is well within your deadline. (or) I have attached a copy of our Claims Submittal Report provided by our electronic claims clearinghouse showing that the original submission date was well within your deadline.

We respectfully request that these claims be promptly processed and that are office is paid for the services rendered to your subscriber as allowed by the State prompt payment regulations. If this claim is further denied, we intend to then file a complaint with the Office of the Insurance Commissionaire.

If you have any questions, you are welcome to contact me directly at (123) 456-7890.

Sincerely,

Your Name

Cc: Patient Name
Home Address

Special Circumstances
Occasionally, because of coordination of benefits or denials from the primary insurance or questions of liability, you will end up filing outside your agreed limit and get denied. In these cases, you have to call the insurance company and find out what their appeal guidelines are for late filing. I have not run across a company that does not have an appeal process for these rare circumstances, but it does vary from company to company.

Prevention
There are always some times when you will fall outside a company’s timely filing deadline. By reviewing your accounts receivable aging report every single month, by ensuring that your review all electronic submission reports (both from your clearinghouse and from the insurance company), and by setting up accounts correctly from the start, you minimize these problems.

This article is not intended as legal advice or as replacement for legal representation. You should always consult a local attorney or tax advisor, as well as your State Board, when setting up any contracts, ads or policies. The reader is responsible for ensuring that he or she is operating within the scope of his or her practice and abiding by local regulations.

Billing Audits and “Red Flags”

Posted on January 15, 2008 by Edward Petty

Angie’s Angles
From a Chiropractic Billing Consultant

For your protection, you should be aware of the Top 10 Red Flags for a billing audit in a chiropractic office. Here they are.

Since this is the beginning of a new year, I will start with the Top 10 Red Flags for a billing audit (in no particular order):

1. “Phantom Billing”—Billing for services not rendered.

2. “Double Billing”—charging more than once for the same service, e.g., using an individual code again as part of an automated or bundled set of tests.

3. “Clustering”—Using only a few codes on the theory that it will average out.

4. “Upcoding”—Using a higher reimbursement code than the code reflecting the service rendered; e.g., billing for complex services when only simple services were performed, billing for brand named drugs when generic drugs were provided, listing treatment as having been for a more complicated diagnosis than was actually the case.

5. “Unbundling”—Using two or more billing codes instead of one inclusive code where
regulations require “bundling” of such claims. Submitting multiple bills in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.

6. “Code Jamming”—Inserting or “jamming” fake diagnosis codes to get insurance coverage.

7. Billing for non-covered services

8. Billing for services that are not reasonable and necessary.

9. Inappropriate balance billing—billing Medicare beneficiaries for the difference between the total provider charges and the Medicare Part B allowable amount.

10. Routine waiver of co-payments and billing third-party insurance only.

The complexity of managing a practice is not a walk in the park. As a Billing Consultant with PM&A, my job is to free doctors from the worries that can accompany running the financial end of a medical practice. I can review and streamline your billing department, train staff, and credential doctors with insurance companies, among other services.

Questions on how any of these might apply to your office? Contact me and I will let you know.
Next month – look for tips on nailing your Financial Consultations!!

Medicare New Claim Form Date Extension

Posted on May 22, 2007 by Dave

Just as a reminder, Medicare has postponed the date on which you must use the new health insurance claim form to June 1, 2007. As of that date all paper claims (including rebills) must use the new claim form.

The date on which you must start using your NPI number is still May 23, so start using the new claim forms when you are ready and make sure your clearing house has the NPI numbers. This applies to chiropractic as well as other health care professions.

If you’re wondering, Medicare delayed the implementation because the government printing office sent out some of the new claim forms that were wrong. You can tell if you have ordered the wrong forms by looking at the upper right hand corner of the claim form. If the red arrow above the word “CARRIER” is touching or close to touching the top edge of the paper, it is the misprinted form.

Email me if you have any questions.

Thanks, Dave

Reference: last Medicare “Communique.”

Chiropractic Patient Financial Plans

Posted on January 3, 2007 by Dave

Are your patient financial plans ready for a changing market? Patient financial plans, and how they are presented, should be carefully reviewed as an important part of your chiropractic marketing plan for the New Year.

According to the Treasury Dept., the use of Health Savings Accounts (HSAs) will continue to increase and by 2010, is expected to cover 25-40 million people. Other reports discount this prediction and say that HSA’s have not taken off as expected because the cost is still too high.(link) HSA’s are accounts, funded with pre-tax dollars by the employee (and sometimes the employer) are an individual savings account coupled with a high-deductible insurance plan. With deductibles rocketing well over $1,000, the HSA option gives the employee pre-taxed money to spend on health related purchases ranging from eyeglasses and braces to massage and acupuncture. The money can also be used for regular medical bills, of course.

The effect of the HSA (and the related flex-spend account) is to make healthcare consumers (your patients) much more aware of costs and prices. A direct result will be patients interested in a deal or cost-savings. As someone who has an HSA personally (with a $3,000 deductible), I am more aware than ever of what each service costs.

Couple that with recent lawsuits nationwide against health care providers that have charged “cash” patients more then insurance patients. The State of Wisconsin recently settled with three major health care systems (ProHealth Care, Wheaton-St. Joseph Hospital and Wisconsin Heart Hospital) to ensure that the discounted rates provided to insurance carriers would also be passed on to patients that are paying out of their own pocket. Makes sense, given the changes to the health care market and our “health insurance crisis”.

For example, a chiropractic clinic may charge $125 for a 99213 exam. If they bill that service to Blue Cross, their provider agreement results in a $52 reduction (for example) with the patient responsible for 20% of the remaining $73 approved charge or perhaps a $20 co-pay. If the clinic billed the same $125 to worker’s comp, there may be a 10% reduction off the fee for “prevailing charges” or UCR reductions. (As an aside, don’t you wish you could do that to your plumber?) Now if the insurance denies the whole charge or if the patient has no insurance, the patient is responsible for the $125 charge. It really isn’t fair if you think about it.

In order to avoid this, clinics, hospitals and doctors have come up with financial plans that try to even this out and stay within the law. As a practice management and marketing solution, ProHealth Care has agreed to provide some charity discounts to patients with income up to 400% of the federal poverty level – about $66,400 for a family of three. Froedtert Hospital, Community Health and Columbia St. Mary’s all have similar plans, giving uninsured patients a 20% discount and another 20% if they pay their bill with 30 days.

Have you reviewed your chiropractic patient financial plans to attract the most patients possible? As a chiropractor, you can appeal to some by offering discounts attached to using their HSA or flex-spend plan. That is as easy as allowing a patient to pre-pay at a discount. The same plan can be extended to any patient paying at the time of service or in advance.

Do your patient financial policies address the real needs of your chiropractic patients while still maintaining your profitability? Do your financial plans help you attract the types of new patients you want to see? This is an important element in chiropractic marketing, new patient acquisition as well as patient retention. Make sure you review these as the New Year begins and feel free to contact us for ideas or fine-tuning.

Dave Michel

Personal Injury Lien Form For Chiropractic Office – Wisconsin

Posted on October 31, 2006 by Dave

Personal Injury Lien Form For Chiropractic Office – Wisconsin
[ Download/View File ]

Changes in Personal Injury Lien Form

Posted on October 31, 2006 by Dave

As part of our chiropractic practice management program, we have always insisted that patients sign a lien form from your office when they are being represented by an attorney on a personal injury case. It is most important to have the patient sign the lien and then send a copy of that to the attorney. Our policy is that the attorney did not need to sign and return it to your office to make it enforceable under Wisconsin Law.

However, a recent Supreme Court decision in Wisconsin has changed this. There are now a couple of additional steps to take to make sure that your lien will hold up in Wisconsin.

In the recent case of Yorgan v. Durkin, the Wisconsin Supreme Court has decided that the enforceability of your lien is questionable unless both the attorney and the patient have signed it. According to Attorney Dan Riegleman, we need to take the following additional steps:

“1. The most (and most obvious) option is to ensure that a patient’s attorney signs the lien form. Office staff should be encouraged to regularly follow up with the attorney to ensure that the form is signed. …

“2. If the attorney adamantly refuses to sign a written lien form, a chiropractor should seek a “Letter of Protection.” A letter of protection is a written document, typically provided by the attorney, which assures or otherwise promises a chiropractor that all of a portion of a patients bills will eventually paid when the case is settled ….”

You may find a copy of our new lien form at this link on our web site. Link

If you would like a copy of Attorney Riegleman’s newsletter, Chiropractic Law, just call his office at (262) 246-4606 and ask him to add your name.

Chiropractic Insurance Updates — Sept., 2006

Posted on September 11, 2006 by Dave

New Claim Form
As you may know, there is a new paper insurance claim form. For those of you that bill electronically (which should be all of you), you still occasionally use paper claims. On October 1, 2006, there will be a new HCFA 1500. The only major change is to allow the use of the NPI number on the claim form. You’ll have until February 1, 2007 to switch over. So, don’t stock up on too many old claim forms now.

Get Your NPI Now
Which brings up the NPI (National Provider Identification) number. You will need to get one for each provider in your clinic and one for your clinic. It takes about ten minutes to apply online and get your number(s). You can get the NPI here: https://nppes.cms.hhs.gov/NPPES. You will have to use your NPI on all claims submitted after May 22, 2007.

Medicare Electronic Payments
Lastly, Medicare is pushing hard to get you to accept your Medicare payments electronically. It actually is better – the check goes directly to your bank account and you get an EOB showing the payment and when it was made. The only thing you don’t get is the satisfaction of opening the Medicare envelope with a check inside. You don’t HAVE to accept electronic payments yet, unless you make any changes to your Medicare account (add a provider, add a reassignment, change a tax id number, etc). If you have a change, Medicare requires you to convert to electronic payment.

If you want to convert now, go to www.wpsic.com/edi/pdf/edi_medb_eft.pdf and download and complete the simple form with your bank account information. Providers simply need to complete this short form, mail it to their Medicare contractor, and include a voided blank check. Medicare payments will be made directly to your bank in as little as two weeks.

Any questions? Sure you do! Just ask Dave@PMAWorks.com