Tag Archives: reimbursement

Managing Your Coordination of Benefits

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insurance benefits

YOUR GUIDE TO COORDINATION OF BENEFITS AND WHO PAYS FIRST

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For more info on insurance:

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

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

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

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Welcome to your best chiropractic year!

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

  • Health Reimbursement Arrangement
  • Health Savings Account

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

Let’s dig into each one!

What is a Health Reimbursement Account? (HRA)

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

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

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

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

Takeaways:

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

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

Takeaway:

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

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

The employer owns this account.

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

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

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

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

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

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

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

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

Adios for now!
Lisa

“Increasing your collections through better billing and documentation.”

Anthem Chiropractic Network Reductions

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(Wisconsin, April 4) Chiropractors in WI received certified letters from Anthem BCBS announcing that they are initiating a sweeping reduction of their chiropractic provider network to supposedly “right size their provider network as a result of the ACA”.

According to Mr. Dave Michel of Petty, Michel & Associates, if you have one of these letters, you’ll be removed from the BX network on Sept 30 “without cause”, as allowed under your provider agreement.

He says that it looks like they may be targeting larger clinics in each city with higher utilization and also possibly those with a focus towards wellness,and that this doesn’t bode well for their customer base.

Dave mentioned that a similar tactic was used by insurance companies in Massachusetts with the introduction of “Romney-Care” in 2006 and after the hue and cry, chiropractic offices continued to grow. This has also been the case with offices that we have worked with when the doctor was booted from a network – stats go up!

In many cases, the out of network benefits are close to those in network.

Dave has written a letter that you can customize and send to your patients should you get hit by an insurance company claiming they need to “right size.” You can download a copy of this letter as a Word file with the link provided below.

A key to survival is patient education, not only on chiropractic, but also on chiropractic benefits. This is why we stress the Patient Financial Consultation, or the Post Report of Findings.

Lastly,  Dave recommended working together as a group with your state associations and respectfully confronting any insurance company that discriminates against chiropractic services with the facts.  And the facts are that chiropractic care doesn’t cost… it pays.

While you may not practice in Wisconsin, there may be a time when you receive such a letter and if you  do,  these suggestions  can help.

For PM&A clients, if you have received a letter like this, let us know and we’ll work with you on your options.

Sincerely,

Ed

Dave Michel’s Letter to patients: Anthem Termination Letter