Medicare Explanation for Chiropractors

Sage Medicare Advice from an Old Chiropractor

aka

Chiropractic Rules of the Medicare Road

First question: Enrolled vs. Not Enrolled

When a chiropractor graduates from college, the first thing he needs to work on is getting his license to practice.  Next, he needs to get enrolled in Medicare.  Why?  Because it is against Federal Law to treat a Medicare beneficiary unless the treating doctor is recognized by Medicare as a provider and they only recognize providers who have enrolled and been approved through their credentialing process.  So, since it would be a Federal crime for anyone uncredentialed to provide medical care to a Medicare beneficiary, unless you are planning to send anyone over 65 years of age down the road to another doc, you have to enroll or you will inevitably end up violating federal law.  Period. Furthermore, if you haven't billed Medicare in over 18 months (you'd have to verify that number), they will drop you as a Medicare approved provider and you will have to re-enroll all over again to restablish your status.

Next question, Participating or Non-Participating

Isn't that the same question as enrolled or non-enrolled?  No.  A participating provider (PAR) is one who will accept assignment of the patient's Medicare benefits for covered services. What this means is that when the covered Medicare patient comes in, you will accept their co-insurance  will bill Medicare for the total amount and then wait for Medicare to reimburse you the balance of the Medicare approved rate later.

A non-participating provider (NON-PAR) is one who chooses to have the patient pay the total Medicare approved rate for the covered service at the time services are rendered and will then bill Medicare for the total amount and let Medicare reimburse the patient Medicare's portion of the Medicare-approved rate for the covered service.  

An important thing to know... a NON-PAR can choose, on a claim-by-claim basis, to accept Medicare assignment and act as if he were a PAR,  taking the patient's co-insurance as partial payment from the Medicare-covered patient at the time of service and Medicare will then send the NON-PAR the balance of the Medicare approved rate later on. This is choice is indicated by checking "YES" in  box 27 on the CMS1500 form that indicates that the provider "accepts assignment." 

So, if I can be a NON-PAR but act as a PAR, why would I consider agreeing to be a PAR?  Well, for one, you get on Medicare's provider list. Woo-Hoo!  What a great marketing tool that is (he said sarcastically).  Also, the medicare approved rate for PARs is about 15% higher than the rate for NON-PARs who opt to bill as accepting assignment. 

Is there any benefit to being NON-PAR? Well, as a NON-PAR who requires full payment at the time services are rendered (in other words, a NON-PAR who does not accept assignment), you can charge more than the Medicare approved PAR rate up to a "limiting charge" which is about 15% higher than the PAR approved rate. This sounds a lot better.  BUT (notice the big but), the rate charged to the Medicare patient must be no more than the lowest rate offered in your office, including any time-of-service discounted rates.  

Covered Services Vs. Non-Covered Services

The Medicare laws only deal with covered services.  In a chiropractor's office, that is simple.  Or at least it should be.  That is because the inclusion law which allowed for Medicare reimbursement for chiropractic specifically allows only for the reimbursement for the adjustment to the spine to correct a subluxation.  So, the only covered CPT  service codes are 98940, 98941 and 98942.  

• No, extra-spinal manipulations are not covered services. 
• No, exams are not covered services.  
• No, x-rays are not covered services. 
• No, physiotherapies (like electric stim, ultra-sound, massage, myofascial release, manual therapy, exercise therapy, neuromuscular rehabilitation, etc.) are not covered services.
  

The only procedure provided by a chiropractor which are covered under Medicare Part B is manual adjustment or manipulation of the spine. Simple, right?  Well, almost.  The truth of the matter is that even that is a covered service only for two select segments of our population over the age of 65 years.  For every other single person on the planet, there are no Medicare covered services at all which are provided by a chiropractor.

The first segment are those seniors who are enrolled in Medicare Part B, and pay a monthly insurance premium to Medicare and only after meeting an annual out-of-pocket deductible. That's right... Medicare Part B is a just a government insurance policy that has a provider panel of particpating doctors, has a $135 annual deductible, a 20% co-insurance, and a fixed monthly premium of $96.40.  If the patient is not enrolled, then they are not covered.

The second segment are those seniors who are enrolled in a Medicare Part C, 3rd Party HMO policy administered by an HMO (like Kaiser Permanente's plans, or some other HMO product) that the chiropractor is independently contracted with.

So, in summary, covered services are 98940/1/2 delivered to Medicare Part B enrollees and Medicare Part C enrollees who selected an HMO Company that the provider has contracted with.

Medicare Provider Obligations

Well, a lot of that is described above, at least indirectly.  But, I will spell it out here... As an approved/enrolled Medicare provider...

1.  You have to provide documentation of your care that meets Medicare guidelines. That is beyond the scope of this blog, but Googling the term "Medicare PARTS" is a good starting point. You should also consult your state chiropractic association.

2. You must bill Medicare for all covered services rendered. If the covered service is medically necessary, you should include a code modifier AT to indicate that this service was delivered under an Active Treatment plan and thus should be reimbursed according to the Medicare policy.

3. You must notify the patient in advance of treatment if their covered services will be denied reimbursement by Medicare by having them complete and sign an ABN form, the Advanced Beneficiary Notice. When billing Medicare for a covered service that will be denied as maintenance care, you must put a code modifier "GA" to indicate that an ABN form is on file. More on that below...

4. You must collect the annual deductible from the patient and thereafter, whatever the patient's financial responsibility is for each visit. Unilaterally reducing the patient's financial obligations under the Medicare rules is considered Medicare fraud, a Federal crime.

5. You may not charge less than the Medicare approved rate unless you are also making this rate available to all of your patient base. To offer special bonuses, gifts, discounts or other incentives greather than $10 in value is an inducement to seek reimbursible care and is considered Medicare fraud.

6. You may not charge more than the respective Medicare PAR or NON-PAR approved rate (when filing as "accepting assignment") or more than the "Limiting Charge" (when filing as "NON-PAR not accepting assignment").  Overcharging is considered Medicare fraud.

7.  Medicare considers services delivered on a maintenance, palliative or non-restorative basis non-medically necessary and thus billing these covered services as medically necessary is considered Medicare fraud.  To make sure that everyone recognizes this distinction overtly, Medicare requires that chiropractors add a modifier "AT" to each billed covered serviced when it is provided in the context of a medically necessary care plan.  "AT" stands for Active Treatment. On the other hand, providers are still required to bill non-medically necessary, but  covered services. But you must drop the "AT" ,  modifier.  You are also supposed to an ABN signed and then you'd  ad a different modifier, "GA" for covered services that are delivered under maintenance care for which an ABN is on file.  The only time a provider can avoid billing altogether is when an ABN is fille out and the patient chooses Option 2.  

Just Give Me The Bottom Line...

All this talk about federal crimes is enough to get a person nervous.  And I hate to admit this, but it has taken me about 7 years to finally get this boiled down, so let's just say I've been nervous for a while. Below are the basic guidelines that I recommend to keep you on the straight and narrow...

1. Enroll: Enroll in Medicare or send everyone over 65 to another office.  Once enrolled, decide for yourself whether you want to participate or not.  The implications are not that significant in terms of your provider obligations so just pick the one that sounds better to you.

2. Document: Learn how to document in compliance with Medicare guidelines. Consider it your obligation to your patient, yourself and your profession.  Just do it right.

3. Intake Paperwork: Add a "Medicare Coverage" Statement: Include a signed acknowledgement in your standard intake paperwork that every patient signs that says that they understand the Medicare pays according to legislated rates only for adjustments to the spine for the correction of subluxation  for Medicare Part B enrolled patients and that payment for any other services are the financial responsiblity solely of the patient.

4. Active Care: If a Part B enrolled patient (Or Part C if you are contracted with the respective HMO) comes in with a new complaint or a re-ocurrence or flare-up of a chronic complaint, document the case properly with an established care plan, collect the patient's portion as appropriate for your provider status, and then bill Medicare with the "AT" modifier.

5. Maintenance Care: If a Part B enrolled patient  (Or Part C if you are contracted with the respective HMO) comes in on a regular basis for maintenance or just to keep from getting worse, inform the patient that this approach is not covered by Medicare, have them complete an ABN form, collect the total fee from the patient in accordance with the allowed PAR or NON-PAR rate or Limiting Charge imposed by Medicare, and then bill Medicare with a "GA" modifier.  If the patient, in filling out the ABN, chooses "Option 2", this is the only instance wherein the provider does not bill Medicare.

6. ABN Forms: Don't get confused...  This is only for covered services and only when they are going to be denied as maintenance care. Some docs think that if they have every Medicare patient complete an ABN form on the basis that they are using it to explain to a patient that non-covered services are not covered, then maybe some patients will choose option 2 and save them the trouble of billing Medicare for all services, including the covered services.  Don't fall for this mistaken line of thought.  In an audit, this will be percieved as inappropriately using an unnecessary form for the express purpose of tricking the patient into electing to deny himself his due benefit.  

7. Don't Bill Medicare for Non-Covered Services: Lastly, don't bill Medicare for non covered services.  They won't pay and it just complicates things. Bill Medicare for 98940/1/2  performed on Medicare Part B enrollees only. If you are a contracted provider with an HMO that has a Medicare Part C plan, then bill 98940/1/2 for those patients also.  Services beyond 98940/1/2 for these patients as well as all services provided for any other patients should be withheld from any Medicare billings and be paid for by the patient at the time of service.

8. One Important Exception to #7: Keep in mind that in very rare cases, a secondary policy may pay for services that Medicare does not cover. So Medicare has a requirement that, at the specific request of the patient, the provider must bill Medicare for all covered and non-covered services so that the billing information may be forwarded for possible compensation by other 3rd party insurance policies. When billing for non-covered services, you should add a "GY" to indicate that this is a service that Medicare does not cover.

Let's sum up the critical points one last time...

• Medicare only covers adjustments. All other services are non-covered.
  
• Medically non-necessary adjustments will be denied. (no "AT" modifier = no "Active Treatment" = non-restorative, preventative or maintenance) 
  
• ABN is only for adjustments that will be denied, if you have an ABN (which you'd better have in this case) then you would bill with "GA" modifier. 
• Never need to include non-covered stuff in ABN forms. 
• No need to bill non-covered stuff to Medicare at all, ever, unless patient asks, then you have to bill everything. 
• No need for ABN unless maintenance care, so don't use to try to get out of billing for covered services. 
• And non-covered services can be charged on a patient pay, cash-basis without any notification required to Medicare.
• This ties it up for me... Oh yeah, and treating a Medicare covered patient ifyou are not enrolled in Medicare is illegal - No opt out available for chiropractors.

That is about it.  I think that short of proper documentation, and a more general discussion about whether chiropractic belongs in Medicare, this about covers Medicare billing. If you have any questions, please contact me at drharriott@gmail.com.  I present this not because I am an insurance or a Medicare expert, but because, like you, I need to know this and why not share what I learn.

Have fun, at least until Medicare folds (currently projected for 2017)