Tag Archives: medicaid

Ask Lisa: What the Heck is HETS? And Other Helpful Resources

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SPECIAL ANNOUNCEMENT RELATING TO THIS MONTH’S ARTICLE

KMC University is hosting a live “Answer Call” to help you take action now on the CMS HETS update.

Keep More Cash: Don’t Let the CMS HETS Update Disrupt Your Revenue
Presented by: Rebecca Scott, CPC, CPCO, CPB, CPPM
Date: TODAY! May 7, 2026
Time: 1:00 PM – 2:00 PM (MT)
For more information read their newsletter

Download the Free Template NOW
Insurance Benefits Verification Form(docx)

If you have received communications from Medicare regarding HIPAA Eligibility Transaction System (HETS) requirements, keep reading for information that will be helpful as you navigate if this applies to you.

First don’t panic if you received communication instructing you to register … HETS is only a beneficiary eligibility tool that will sync within your Clearinghouse or EHR Program, and may apply to you only if both of these scenarios exist in your office:

  1. Insurance Verifications are part of your practice operations. (Verifying is a key component to your revenue cycle and keeping you in the know for your patient financial consultations.)
  2. You normally use your clearinghouse or EHR Program as your insurance and Medicare benefits verification tool.

If you do not pay extra for and do not have the benefits eligibility verification service with your clearinghouse or EHR Program, HETS is not applicable to your office.

You may be now asking… What are the best third-party payer verification tools? Here’s a current breakdown for you:

Medicare Verification: Connex is CMS Medicare’s Portal to use to verify eligibility and benefits, and claims. If you do not have a Connex account you have two options:

  1. Apply for an account Here
  2. Add this service to your Clearinghouse contract for an extra fee. If you go this route, you will need to follow the HETS policy and procedure. Learn more here: HETS

Medicaid Verifications: Each state has its own Medicaid Portal/website for checking eligibility in advance of treating your patient. Use your favorite search engine to search for your state’s Medicaid online Portal website. Keep in mind each website may have a different default browser that works better; for example, Google Chrome may sync better with the site vs. MS Edge.

Major Commercial Payers:

  • UHC/Optum/AARP: Verify here UHC Optum or call the Provider Line on the patient insurance card. Make sure to get the representative’s name and a call reference number if you need to follow up on a claim once the remittance comes back.
  • UMR: Verify here UMR or call Provider Line on the patient insurance card. Make sure to get the representative’s name and a call reference number if you need to follow up on a claim.

Use Availity Portal for patient benefits and eligibility: Availity

Currently for these payers:

  • Aetna
  • BCBS Plans, most states
  • Humana
  • CIGNA
  • Well Care for Medicare/Medicaid

Implementing and maintaining patient benefits verification will help you plan ahead for your financial consultations which is an important part of managing your revenue cycle and generating income.

Follow-Up Questions? Just Ask…

Lisa
920-334-4561

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

Ask Lisa: Setting Up Finances With Your Patients

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BJ Palmer had a quote: “Chiropractic is health insurance. Premiums small. Dividends large!”

Following this super quote, we have worked with offices for many years schooling them into implementing these mottos:

  • We will accept all patients, regardless of their ability to pay, but we also must operate the clinic as a proprietary business, i.e., for profit, and the patient must want the care–not just “want a discount.”
  • Each case will be individually handled and patients will receive a copy of their financial arrangements.
  • Each patient file will have a copy of the patient’s individual financial arrangements.

How does the successful office achieve these goals?

First, to comply with Centers for Medicare and Medicaid’s No Surprises Act as a covered entity, each patient will have an idea what our range of charges are and that the charges will vary depending on what is done. Explain that the adjustment charges will vary from $XX to $XX, therapies will add $XX to $XX, and exams, diagnostic tests, etc. will add to that. Typically the average office visit will be from $30.00 to $140.00 per visit. This can be shared when the new patient calls in for their first appointment, or placed on your website.

Second, determine if you will be filing claims to insurance, and if patient has a copay or deductible. If there is a financial barrier with co-pays or deductibles, work with the patient during your meeting with them so that the patient does not drop out of care for financial reasons. To stay in compliance, note any waived fees or co-payments on your financial form, indicating why they were waived (no job, too many bills). Alert payment arrangements in your practice software so that the front desk and anyone doing follow-up knows exactly what the patient has agreed to pay each visit.

The patient should already have a good idea after Day 1 from the Report of Findings and the schedule you just worked out with them how many times they will be coming in. Ask the patient if they will have any problem with this and watch the patient to make sure that they will be comfortable with the fees you are presenting (previously calculated prior to meeting with patient).

(These next sections are specific to Wisconsin offices and offer examples. However, if you find this information interesting and you want more information and are outside WI, contact us for further information.)

If you are not filing to insurance, patients are considered self-pay. Let the patient know that they must pay at the time of service for any discount given. To be successful, you cannot reduce your fee while running up patient balances.

Any discount or special fee must be noted on the financial agreements and in the computer. The financial agreement must indicate why there are special discounts given. This can be simply noted in the space provided, such as “patient discount to $30 per visit-financial hardship” or “patient has just started new job-discount given to $30 per visit”. The CA or doctor, and patient, must sign the form.

For self-pay patients who can afford care, are on a routine schedule and show up, in order to give a discount they should be required to prepay, for a package of XX visits, typically with up to a 35% discount.

With the above policies in place, you can help many more people increase their health dividends, removing any financial barriers. Implementing these steps are key to expanding and growing your practice!

If you have any questions regarding financial arrangements and/or insurance please feel free to reach out to me.

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

Insurance Key References

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

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

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

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

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

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

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

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

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

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

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

Downloadable Reference Guide: Insurance Key References

“No Surprises Act” effective January 1, 2022

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

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

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

Lisa