Tag Archives: billing

Ask Lisa: Cracking the Code – ICD-10 Code Revisions Start on October 1

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lock and key cracking the code of ICD-10 insurance codes

Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes for proper reimbursement. The translation is called the International Classification of Disease codes, or ICD-10-CM*. There are annual updates which may include deleting codes, adding codes, and minor edits to existing codes.  Keep reading for information regarding ICD-10 changes for 2026.

Although there are very few changes in 2026 relevant to chiropractic coding, the updates contain 487 new, 28 deleted, and 38 revised codes. The 2026 ICD-10 codes will be used for patient encounters from Oct. 1, 2025, through Sept. 30, 2026.

The new codes listed below may be relevant to your patient encounter:

  • Pelvic Pain
  • R10.20 Pelvic and perineal pain unspecified side
  • R10.21 Pelvic and perineal pain right side
  • R10.22 Pelvic and perineal pain left side
  • R10.23 Pelvic and perineal pain bilateral
  • R10.24 Suprapubic pain

And new codes related to socioeconomic circumstance:

  • Z56.6 Other physical and mental strain related to work
    • Workplace stress
  • Z56.89 Other problems related to employment
    • Furloughed
    • Underemployed
  • Z59.02 Unsheltered homelessness
    • Lives in a homeless encampment
  • Z59.19 Other inadequate housing
    • Poor housing weatherization
  • Z59.86 Financial insecurity
    • Z59.861 Financial insecurity, difficulty paying for utilities
    • Difficulty paying for electricity
    • Difficulty paying for heat
    • Difficulty paying for oil
    • Difficulty paying water bill
    • Utility disconnect notice due to inability to pay
      • Excludes2: inadequate housing utilities (Z59.12)
    • Z59.868 Other specified financial insecurity
      • Bankruptcy
    • Z59.869 Financial insecurity, unspecified

Coding and Billing Tips:

  • Make sure if you use a new code listed above, you relate it in your SOAP note to the patient’s condition and why they are seeking care.
  • If you bill a 98941: 3-4 region adjustment, make sure you have at least three ICD-10 subluxation codes (The M99.0X series) on the claim.
  • If you bill a 98942: All 5 regions adjustment, make sure you have at least five ICD-10 subluxation codes (again the M99.0X series) on the claim.

If you are interested in obtaining the entire file of new/updated/deleted ICD-10 Codes, click this link from the Centers for Medicare and Medicaid Services:

https://www.cms.gov/medicare/coding-billing/icd-10-codes#CodeFiles

And, BTW… we still make house calls!  Not collecting what you are owed? Something just doesn’t seem right with collections and your deposits? Give us a call to discuss if an onsite visit or video conference is right for your office.

Happy Birthday Chiropractic! Celebrate the entire month of October!

Lisa

920-334-4561

*CM refers to the ICD-10 coding system used in the United States.Sources:

Sources:

ChiroCode
Center for Medicare and Medicaid Services (CMS)

Why Clear Roles Build a Stronger Chiropractic & Healthcare Practice

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team players wearing staff hats front desk billing promotion marketing

Better teamwork, smoother operations, and improved patient care all start with clarity.

Years ago, I visited a chiropractic office where the doctor was frustrated: patients weren’t keeping appointments, and he blamed his front desk staff, “Sue.” The problem wasn’t effort—Sue was polite and friendly—but she had no clear job description, no checklist, and no real understanding of her responsibilities.

Once we clarified her role, outlined simple procedures, and scheduled regular reviews, the practice quickly improved. Patients kept their appointments, and both the doctor and Sue felt more confident and motivated.

This is a common issue: when roles are vague, results suffer. But when roles are clear, teams thrive.

—

The Three Elements of Every Role

According to the Goal Driven System, each role should include:

  1. Purpose – Why the role exists.
  2. Outcome – The measurable result it should achieve.
  3. Procedures – The specific actions to reach the outcome.

Example – Front Desk Role:

  • Purpose: Help patients achieve health goals by ensuring they stay on schedule.
  • Outcome: Patients consistently keeping appointments.
  • Procedures:
    • Greet every patient with a smile.
    • Answer the phone warmly.
    • Confirm each patient leaves with their next appointment scheduled.

—

 Action Steps for Your Practice

  1. Have every team member list their roles.
  2. Define the purpose, outcome, and 5–10 key procedures for each.
  3. Add measurable indicators (e.g., % kept appointments, total visits).
  4. Review and rehearse roles regularly, just like a winning sports team practices.

Clear roles create accountability, boost morale, and drive better patient care. Keep it simple, keep it consistent, and keep it fun.

Stay Goal Driven,

Ed

Ask Lisa:What’s up with BCBS and Therapies Reimbursement?

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Within the last two years, Blue Cross Blue Shield started requiring precertification (precert or pre-auth) on select plans for therapy codes. This came about because by Insurance Equality law they can’t require precertification for chiropractic services 98940, 41, 42, and 43, so they got around that by requiring it for many therapy codes regardless of the provider type.

If you call to verify coverage for “chiropractic”, the customer service representative (CSR) may tell you that there is no precert required for chiropractic. They may or may not understand that they have separate precerts for physical therapy codes. You’ll need to give the CSR the specific codes you want verified for coverage and limits.  You can also verify benefits and usually are able to request authorization for therapies using Availity: https://www.availity.com/providers/

Specific Claim Tips for billing BCBS: 

1)  Qualifier 431: Make sure you are entering in Box 14 OR 15, the 431 qualifier to indicate onset date within a treatment plan.

2)  Taxonomy code for chiropractic, which is 111N00000X, in Box 33. Some states’ BCBS plans require the use of a ZZ prefix before the taxonomy. Please ask when verifying benefits with your patient’s state plan what their billing requirements are. For example, is the ZZ required in front of the taxonomy code? You can add the taxonomy code for specific payers by going into your Maintenance application in your practice management software, and once added to the payer information, it will automatically generate the claim form with this information defaulted.

3)  Modifiers: I understand some of you are using XS GP for therapies and are getting paid. Great! But use this with caution. The XS modifier indicates a separate and distinct service done by a different provider than the one billing under. Better to use GP and 59 for accurate billing if one licensed provider did the therapy and chiropractic adjustment. Your 59 modifier indicates a separate, distinct service but does not distinguish between providers.

What about 98940-98941-98942? For your Medicare Advantage plan patients, make sure to use AT modifier indicating the treatment was active care vs. maintenance/supportive. BCBS usually will not pay for the GA modifier use indicating maintenance/supportive care services were provided. You’ll want to advise the patient ahead of time they will be financially responsible for their maintenance/supportive care, while presenting your cash options or packages offered. Use AT when billing BCBS Medicaid plans, all states, while the patient is under a care plan.

Where are the preauthorization requirements headed?

Here’s a recent (June 2025) article from Blue Cross Blue Shield regarding precertification requirements going forward:  BCBS News

Here’s what it states: 

“Reducing prior authorizations:

BCBS companies routinely review their prior authorization requirements, and many have taken steps to reduce the volume of prior authorization requirements in recent years. We will build on these efforts and commit to reduce in-network prior authorization for medical services as appropriate for the local market each plan serves with demonstrated reductions by Jan. 1, 2026.”

Reach out to us lisa@pmaworks.com or dave@pmaworks.com, and we can give more “boots on the ground” info for your specific state.

Lisa

920-334-4561

Please share this newsletter with your colleagues so they may benefit from this information too!

Ask Lisa: When Your Patients Need Extra Help

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payment terms for chiropractic care plan

When Your Patients Need Extra Help

Tips and Sample Policies for Financial Consideration Cases

It does happen from time to time… patients will need care but are not in a position to be able to afford care. To maintain your goals of:

  1. getting sick people well and maintaining health through chiropractic, and
  2. remaining profitable, you do have a duty to provide care to those that cannot afford care.

The two goals do not conflict.  And you do not want a patient to discontinue care because they have financial problems. Your clinic should have policies in place to enable a patient to get care – regardless of their financial ability. For active clients sample policies can be downloaded from the PMA Members Site. For all others sample policies are included in our Patient Financial Consultation Tool Kit.

Immediately following the Report of Findings, the CA should meet with the patient (the Post Report) to work out any financial arrangements, and to answer any questions that the patient may have concerning the policies of the clinic.

If the patient expresses concern over their ability to pay for the services that will be performed, go over the different fee policies that you have and see if one of these programs will handle their financial problem.

First discuss payment at time of service and prepayment options.

Here is a sample Introductory Script you can utilize:

[Patient Name], it sounds like you know how important our care is for your condition, and we want to be able to treat you. We understand that money can be a problem and know that you have to eat, pay rent, etc. I would like to set you up on our individual “Financial Consideration” program. It will provide you with the care that the doctor has outlined, at a price that you can afford.”

If the patient pushes back, inquire, empathetically, if the problem is truly a financial problem, or if they have a problem with the treatment program prescribed.

OTHER TIPS

  • Avoid writing: “(“Clinic Name) agrees to waive $100 of patient’s $200 deductible.”
  • We suggeest this be worded: “(Clinic Name) agrees to accept $100.00 from patient towards their deductible and waive any remaining deductible.”
  • When writing up the agreement, please remember to use a “per visit” amount only, rather than per week or month.
  • Please note that in talking to patients, they are not a “hardship” case, but a Financial Consideration case.

For active clients sample policies can be downloaded from the PMA Members Site. For all others sample policies are included in our Patient Financial Consultation Tool Kit.

Contact us if you need help accessing the scripts or if you have any questions!

Lisa

920-334-4561

lisa@pmaworks.com

Please share this newsletter with your colleagues so they may benefit from these services too!

Ask Lisa: Not a Robot – But Some Cool Technologies to Advance Your Practice.

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Not a Robot – But Some Cool Technologies to Advance Your Practice, and Best Software Programs for the Chiropractic Practice

My computer technology training started in the 1980s. Here we are in 2025, and the demands for and surges in healthcare technology are real. But now I write with a fresh perspective. Technology can benefit, and even potentially save, your practice while maintaining human connection and personalized care. We’ve done some research for you – keep reading to learn about some healthcare technology to help your practice grow… and a link to the best practice management software programs based on Capterra surveys.

Let’s start with the patient record or SOAP note.

Your practice management software should work for you and the patient, not against, in recording subjective complaints that meet documentation standards and best practices.

Diagnostics Technology can include the use of Goniometers, scanners such as Surface EMG (sEMG), NeuroThermal, x-ray, inclinometer, and newer traumatic brain injury scanners such as quantitative electroencephalography (say this slowly, out loud).

In conjunction with your objective diagnostics, your practice management software should be a gateway to a solid clinical assessment of the patient’s condition, care plan, and expected outcome. Is your program user-friendly in assessing a patient’s case, and does it offer you the ability to present a sound assessment and expected outcome?

Using technology to administer and record a precise adjustment can include the use of the Activator, Impulse Adjuster, SOT (Sacro-Occipital Technique) Blocks, Impulse Adjusting Instrument, ArthroStim Adjusting Tool, Pulstar FRAS Adjusting Instrument, and the Atlas Orthogonal Percussion Instrument.

How to improve patient compliance with care plans
The use of AI and algorithms to assist in customizing treatment plans that patients stay engaged and comply with is at the forefront of the future of chiropractic care.(1) Technology devices as part of a patient’s care plan to help alleviate subjective complaints can include Utrasound and Laser units, electronic pulse devices such as Shockwave Therapy (extracorporeal shockwave), and Pulse RadioFrequency devices.

Ready to learn which software programs made the top-rate list? Click on the link below to review the top practice management software programs that made Capterra’s(2) list. Note that billing and invoicing capabilities are also part of the ratings:

https://www.capterra.com/chiropractic-software/

Other than the ratings included in the link, what else should you look for before investing in new practice management software, if you’re in the market?

Stephanie Maharjan, a brand leader at WellReceived, a corporate member of the American Chiropractic Association, gives the following guidelines in researching software:(3

  1. Ensure it is compliant with HIPAA and CMS
  2. Reviews from other chiropractic practices. When assessing a new software solution, gather reviews from other chiropractic clinics. Select reviews from a few clinics and see if they still use the technology. Stephanie points out that reviews and feedback are a great way to understand areas for improvement so you can boost patient retention.
  3. Ask for a free trial or a demo before committing to new technology, so you can test various scenarios and evaluate its functionality. Assess how well the technology meets your clinic’s specific needs and determine if there are any workarounds.

Email me if you would like to chat!

Lisa
lisa@pmaworks.com

References:

  1. https://www.capterra.com/
  2. https://neulifechiro.com/technology-in-personalized-chiropractic-care/#ai-and-data-analytics-in-chiropractic-care
  3. https://www.acatoday.org/news-publications/using-technology-to-improve-patient-care-in-your-chiropractic-clinic/

Ask Lisa: The Art of Navigating Insurance Network Participation

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participation in insurance networks building blocks

One of the most critical decisions you will need to make in your practice is, should you be “in-network” with a payer group, or out? It’s a tough choice, and one size does not fit all.

So, what do you do?

First, determine which companies you already are in network with, and assess.

  • Do you have a contract?
  • What are your obligations as a participating provider?
  • 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?
  • Are you enrolled as a provider with the Veteran’s Administration in your area?

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?
  • Do they want you to participate in their worker’s 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?

Next, make sure you have a profile set up with the National Council for Affordable Quality Healthcare (CAQH) universal provider database and 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, to determine

  • What percentage of your reimbursement comes from insurance?
  • What percentage comes directly from patients?
  • Which payers are you mainly seeing patients from and 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?

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.

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! We also will run those audit reports to assess if you’re getting the best bang for your buck.

Email me for assistance with how these processes work for your practice. You may reach me at Lisa@pmaworks.com.

Lisa

Ask Lisa: Blue Cross Blue Shield Antitrust Settlement – Action Needed

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Are You Eligible?
If you or your clinic provided care, equipment, or supplies to any Blue Cross Blue Shield (BCBS) patient between July 24, 2008, and October 4, 2024, you are likely included in this settlement.

What’s This About?
A $2.8 billion settlement has been reached in a lawsuit alleging BCBS companies limited competition and underpaid providers.

Your Options:
• File a Claim: To receive any payment, you must file a claim by July 29, 2025.
• Do Nothing: You will not get any money and cannot sue BCBS over these issues later.
• Opt Out: If you want to sue BCBS on your own, you must have opted out by March 4, 2025.

How Much Will You Get?
The fund will be split: 92% to hospitals/facilities, 8% to professionals (including chiropractors). The exact amount depends on how many claims are filed.

How to File:
Go to the official provider settlement website and click “Submit a Professional Claim” to file online.

Questions?
For more details, visit the BCBS Provider Settlement website.

Key Deadline:
July 29, 2025 – Last day to file your claim. Don’t miss out.

Citations:
Settlement Information:https://www.bcbsprovidersettlement.com/Home
Application: https://www.bcbsprovidersettlement.com/Home/ClaimantAccount

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]

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

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”

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

Preparation for the September 7 switch to NGS Medicare

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

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

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

Best, Dave

Billing Audits and “Red Flags”

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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!!