What is Medicare?

Medicare is a federal health insurance program that provides medical coverage for people 65 or older, certain disabled individuals, and for some individuals with End-Stage Renal Disease.

Who runs the Medicare program?

The U.S. Department of Health and Human Services through the Centers for Medicare & Medicaid Assistance (CMS) manages Medicare.

What is Medicare Part A?

Medicare Part A is hospital insurance. This coverage helps to pay for:

• Inpatient hospital care
• Inpatient care in a skilled nursing facility following a covered hospital stay
• Some home healthcare
• Hospice care

What is Medicare Part B?

Medicare Part B is supplemental medical insurance or SMI. This coverage helps to pay for:

• Medically necessary services provided by chiropractors, physicians and a number of practitioners with limited licenses
• Home healthcare
• Clinical laboratory and diagnostic services
• Surgical supplies
• Durable medical equipment and supplies

What is Medicare Part C?

Medicare Part C or “Medicare+Choice” is a set of healthcare options created to give Medicare beneficiaries more choices in healthcare and contractors. A Medicare beneficiary may choose to have covered items and services furnished to him or her through another plan, rather than traditional Medicare. Medicare+Choice plans may include:

• Health Maintenance Organization (HMO)
• Point of Service option (POS)
• Provider Sponsored Organization (PSO)
• Preferred Provider Organization (PPO)
• Medical Savings Account (MSA)
• Private fee for service plan
• Religious fraternal benefit society plan

The beneficiary’s entitlement to Medicare is based on the same criteria, whether healthcare expenses are payable by an HMO or traditional Medicare carriers.

Are patients automatically enrolled in Medicare Parts A, B and C when they turn 65?

No. Medicare Part A is effective the month the individual turns 65, if he or she applies for the benefit within six months of his or her birth month. Medicare Part B is voluntary and becomes effective when the individual enrolls and begins to pay the monthly premium. Medicare Part C is a choice a patient makes when they enroll in Medicare Part B.

How do we know if a person is eligible to receive Medicare benefits?

When an individual becomes entitled to Medicare, he or she receives a health insurance card. This card contains important information that must be included on all claims:

• Name
• Sex
• Health Insurance Claim (HIC) number
• Effective date of entitlement to hospital (Part A) insurance
• Effective date of entitlement to medical (Part B) insurance

My patient has enrolled in a Medicare+Choice plan for which I am not a provider. Who is responsible for paying for my services?

If a patient has coverage through a Medicare+Choice plan but insists on seeing a provider who is not on the panel for that plan, the patient is responsible for all charges.

I have received my license number from the state and have sent in my application to Medicare. Do I have to wait until I received my Medicare number before I can provide services to Medicare patients?

Once you have your license number you can begin to provide Medicare services. However, you should wait to bill for those services until you receive your unique Medicare billing number from Medicare.

What does the word “participating” mean in the context of the Medicare program?

“Participation” in Medicare means that a physician voluntarily enters into an agreement to accept assignment for all services provided to Medicare patients and becomes a “participating provider”.

What does “accepting assignment” in Medicare mean?

“Accepting assignment” means that you will be paid directly by Medicare for your services. The patient is not responsible for paying anything other than their co-payment and deductible. Once you accept assignment you must accept assignment for all covered services for all Medicare patients.

What is a “non-participating” provider in Medicare?

A “non-participating provider” is paid by the patient for their services.

Does a participating provider have the option to accept assignment on certain claims?

A participating provider may accept assignment on a case-by-case basis by checking the “yes” box in Box 21.

Can I change my mind after I have chosen my participation status with Medicare?

You have one opportunity each year to change your participation status for the following calendar year. This occurs during the open enrollment period each November.

How are Medicare reimbursement rates calculated?

Chiropractic services are paid through a fixed fee schedule, charges for which are based on three key Resourse-Based Relative Value Units (RBRVUs). The RBRVU system fixes a national value for each procedure code, based on the sum of the RBRVUs associated with:

• The physician’s time, intensity, and technical skill required to render a service.
• The practice’s overhead expenses, such as rent, office staff salaries, and office supplies.
• Malpractice insurance premiums.

RBRVUs are established locally to allow for variations in practice costs among geographic areas; each pricing locality for a given state has a Geographic Practice Cost Index for each RBRVU.

Physician fee schedules for all Medicare Part B carriers are calculated using one national Conversion Factor (CF). Congress determines the CF each year, considering the projected inflation rate, projected vs. actual claim volume, Medicare enrollment changes, and other factors potentially impacting the Medicare Part B budget.

What does “limiting charge” mean?

The limiting charge represents the maximum amount that a nonparticipating provider may legally charge a Medicare beneficiary for services billed on nonassigned claims. The limiting charge does not apply to charges from participating providers, nor for any services billed on an assigned basis by nonparticipating providers.

May we round the limiting charge?

The limiting charge may be rounded to the nearest dollar is done so consistently for all services. The following formula is used in rounding:

• $.01 - $.49 Round down
• $.50 - $.99 Round up

Does Medicare’s limiting charge apply to my exams, x-rays, modalities, or supplies?

No. Medicare’s limiting charge rules only apply to covered services which are chiropractic adjustments.

We are a nonparticipating provider. Must we always check the “no” box in Box 27?

No. A nonparticipating provider may decide to accept assignment for any claim by checking the “yes” box in Box 27 on the HCFA 1500 form.

May we submit handwritten CMS 1500 claim forms to Medicare?

No. Medicare requires all CMS 1500 form to be typed or machine printed.

What are the most common reasons why Medicare rejects a claim?

The following are the most frequent reasons why a claim was rejected by Medicare:

• Items were stapled, clipped or taped to the claim form.
• Necessary documentation was not included with the claim.
• The patient’s name and Medicare number was not included on each piece of submitted documentation.
• The ink was too light to be read by Medicare’s scanners.
• All letters were not CAPITALIZED.
• The claim was not typed in 10 or 12 point (pica) characters and standard dot matrix fonts.
• Character fonts were mixed on the same form.
• Italics or script were used.
• The form was printed with an old or worn print band or ribbon.
• Dollar signs, decimals, or punctuation was used.
• Information was not entered on the same horizontal plane within the designated field.
• Extraneous data was printed or hand-written on the form.

• Corrections were made using something other than lift-off correction tape.
• Data overlapped into another field.
• Pin fed edges at side perforations were not removed.
• An original red-ink-on-white-paper HCFA-1500 claim form was not used.

What is EFT?

EFT or electronic funds transfer is a form of direct deposit that allows the transfer of Medicare reimbursement directly from Medicare to your bank account.

What are the advantages of EFT?

The advantages of EFT are:

• Reduces the amount of paper in your office
• Saves staff time and the hassle of going to the bank to deposit Medicare checks
• Eliminates the risk of Medicare checks being lost or stolen in the mail
• You can access your money faster

When is Medicare considered secondary?

Medicare is the secondary payer when services are paid for by:

• Working aged
• Working disabled
• End-Stage Renal Disease
• Department of Veteran Affairs
• Worker’s compensation
• No-fault or liability insurance
• Black Lung program

What are Medicare deductibles based on?

Medicare deductibles are based on Medicare’s allowable charges, not the amount paid by the primary insurer. If the primary insurer pays the entire amount of a claim but the beneficiary has not satisfied his/her deductible, Medicare will act as the secondary payer and use the Medicare allowable amount to satisfy the beneficiary’s deductible.

Who is allowed to appeal the denial of an assigned claim?

A chiropractor, the patient, or their representative may request a review of an assigned claim.

Who is allowed to appeal the denial of a nonassigned claim?

Typically, only the patient or the patient’s representative can request a review of a nonassigned claim. However, a chiropractor may request a review only if services were denied or reduced based on medical necessity guidelines, and the chiropractor is liable for the denial or reduction. The chiropractor may also request a review of a nonassiged claim if the beneficiary authorizes it in writing. The review request must include the signed authorization.

What types of hearings are available?

You or the patient may request a telephone or in-person hearing. With a telephone hearing, you may submit additional evidence supporting the claim by fax. At an in-person hearing, you may submit oral testimony and written evidence supporting the claim and refuting or challenging the information the carrier used to deny it.

How do we file a request for a Medicare hearing?

A request for a hearing should be submitted in writing, clearly explaining why the review determination was unsatisfactory. It should indicate the type of hearing being requested. The request, a copy of the review notice, and any additional useful documentation should be sent to WPS-Medicare.

What is the deadline for filing a request for a hearing?

A hearing request must be filed within six months from the date of the review determination. The carrier may, upon request by the patient, extend the period for filing the request for a hearing.

If we lose the decision at a Medicare hearing, do we have any other options?

If a least $500 remains in controversy following the hearing officer’s decision, further appeal may be made to an administrative law judge (ALJ). The hearing decision will include instructions for obtaining an ALJ hearing. The request must be made within 60 days of receipt of the hearing determination.

Medicare sent us a letter claiming that they overpaid a claim. They are charging us interest because it took us more than 30 days to respond. Can they do this?

Yes. Medicare is required to collect interest on overpayments that are not satisfied within 30 days from the date of the initial refund request letter.

Does a supplemental carrier have to pay chiropractic claims in full?

Ever since the passage of Wisconsin’s insurance equality law, there has been uncertainty as to the circumstances under which Medicare supplemental carriers must provide coverage for chiropractic services. Further confusing the issue were the “standardized” coverages allowed under federal and state law. While there are a number of exceptions, the WI Administrative Code describes conditions under which a Medicare patient may be able to obtain additional coverage for their chiropractic services. Ins 3.39 (5) (c) (8) states:

The following required coverages, to be referred to as “Basic Medicare Supplemental Coverage” for a policy issued after December 31, 1990 must include payment in full for all usual and customary expenses for chiropractic services required by 632.87 (3) Stats. Insurers are not required to duplicate benefits paid by Medicare.

There are several major exceptions that allow an insurer to exclude payment for chiropractic services. The most significant includes any policy issued by a self-insured employer for supplemental coverage of Medicare expenses. These plans are covered under federal ERISA laws and are exempt from all state law.

A second exception applies to secondary health policies. These policies are generally issued to retirees still covered under their employer’s health plan. The benefits can be different than those offered under standardized Medicare supplemental plans and, depending on where the plan was issued, may not be covered under Wisconsin law.

A third exception is caused by a continuing argument between the insurance commissioner’s office and some national plans over the definition of when a policy is issued. Any Medicare supplemental policy written in Wisconsin after December 31, 1990 should cover chiropractic services (if it is not covered under one of the two exceptions discussed above). If the policy was issued before January 1, 1991 the plan may argue that chiropractic services are not covered. The insurance commissioner’s office has to resolve these disputes on a case by case basis.

There are enough reasons why an insurer might not be required to pay for chiropractic services under a patient’s supplemental policy that it is a good idea to warn your patient ahead of time that they may have the responsibility to pay for these services. If an insurer declines payment, your most effective approach is to first call the insurer to find out if there is an obvious reason for non-payment (e.g. the employer is self-insured).

If the reason for payment is not obvious and the claim representative is not familiar with Wisconsin law, you may wish to send/fax the insurer a letter, similar to the sample in the next question. If the insurer is not responsive, please send a copy of the EOB with the explanation for rejection to the WCA office and we will write to the insurer on your behalf.

Can you provide us with a sample letter for supplemental carriers that reject our claims?

Re: Patient Name

Claim Number
Dear Claims Manager:

On the above referenced claim you denied payment for chiropractic services. In doing so we believe you have violated Wi. Stat. 632.87 (3)(a) states that No policy, plan or contract may exclude coverage for diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, if the policy, plan or contract covers diagnosis and treatment of the condition or complaint by a licensed physician or osteopath, even if different nomenclature is used to describe the condition or complaint. Examination by or referral from a physician shall not be a condition precedent for receipt of chiropractic care under this paragraph.

(b) No insurer under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, may do any of the following:

1. Restrict or terminate coverage for the treatment of a condition or a complaint by a licensed chiropractor within the scope of the chiropractor’s professional license on the basis of other than an examination or evaluation by or a recommendation of a licensed chiropractor or a peer review committee that includes a licensed chiropractor.

2. Refuse to provide coverage to an individual because that individual has been treated by a chiropractor.

3. Establish underwriting standards that are more restrictive for chiropractic care than for care provided by other health care providers.

4. Exclude or restrict health care coverage of a health condition solely because the condition may be treated by a chiropractor.

Furthermore the Wisconsin Administrative Code Ins 3.39 (5) (c) (8) states:

The following required coverages, to be referred to as “Basic Medicare Supplemental Coverage” for a policy issued after December 31, 1990 must include payment in full for all usual and customary expenses for chiropractic services required by 632.87 (3) Stats.

If there is a reason why you believe your policy is not covered by Wisconsin statutes, please send us a copy of the potion of the contract that you believe exempts you from the law and we will forward it to the insurance commissioner’s office for review.

Thank you very much for your prompt re-processing of this claim.

Sincerely,
Your office name

A customer service representative for WPS-Medicare told me that my claim was denied because the patient “had exceeded the amount of care allowed for this diagnosis.” Is this possible?

It is definitely possible that this statement was made; however, the statement itself is false. There is no limit on the number of adjustments a Medicare patient may receive. As long as the patient’s condition meets the test of Medicare’s “medical necessity” rules, a patient may receive as much care as they need. Medicare uses proprietary methods to determine when they believe care is not medically necessary. When this occurs, it is your signal to use the appeal process described in this section.

When are chiropractors notified about changes in Medicare’s fee schedule?

Medicare’s fee schedules are usually announced through the Communiqué that arrives at a Medicare provider’s office during the last 60 days of the year. This is not always the case; however, and you should check the website for information when policy notices arrive late.

What is the difference between the terms participating and non-participating provider? Medicare has chosen very confusing terms to describe the relationship it has with providers. Many new chiropractors may unwittingly assume that non-participating means that they do not accept Medicare patients. This, of course, is not true. The terms describe the method by which providers receive payments from Medicare.

Participating providers receive payments directly from Medicare. The only time a participating doctor receives money from the Medicare patient is for deductibles, co-payments, or for non-covered services. The doctor bills Medicare for services and the doctor is reimbursed from Medicare directly at the participating provider’s fee.

Non-participating providers receive payment directly from the patient. The doctor is allowed to bill the patient for an amount up to the “limiting charge” listed on Medicare’s fee schedule. This amount is usually several dollars more than the fee schedule amount for participating providers. The patient pays the doctor at the time of service or according to the doctor’s payment policies. The doctor bills Medicare for his/her services and the patient receives reimbursement from Medicare at the “non-participating provider” rate listed on the fee schedule.

Is there a difference in the method Medicare uses to determine medical necessity or to audit participating and non-participating providers?

No. Medical necessity decisions and audits are not based on the provider’s status within Medicare.

What is Medicare’s Integrity Program (MIP)?

Medicare’s Integrity Program (MIP) was established by Congress in 1996 to help reduce payment errors and protect and strengthen the Medicare Trust Funds. The CMS staff and contractors work in a wide range of Medicare program areas such as cost report auditing, medical review, anti-fraud activities and the Medicare Secondary Payer program to improve payment accuracy. In 1996, the Inspector General’s office estimated that 14 percent of Medicare payments were made improperly. Since then that error rate has been cut roughly in half.

Does Congress require Medicare to reach some kind of quota for refunds?

No. Medicare is not required to generate funds through refunds, penalties, or interest. The program is funded by Congress. Overpayments recovered, fines, and penalties go to the Medicare Trust Fund.

Are providers that make honest mistakes penalized by Medicare?

Providers that make honest mistakes may have to correct the mistake by making a refund to the patient or Medicare but they are not subject to further penalties by Medicare.

What portion of Medicare Integrity Program funds are used for claim and medical necessity review?

Approximately thirty three percent of MIP funds are used for medical review. Most of the medical reviews do not require WPS-Medicare to ask for or look at individual patients’ health care records. Often, medical review is conducted by simply examining the claim itself and the information that has been submitted for payment. If they need more information, they examine attachments to the claims and patient history files. In a small percentage of cases, they ask for and look at actual medical records to confirm that the services were rendered to the patient as reflected on the claim, the coding of the service is correct, and the service was covered by Medicare. Medicare pays more than 95 percent of the claims submitted to the program without obtaining medical records.

The vast majority of the improper payments Medicare makes are for services that appear correct on the claim form but are determined to be medically unnecessary after reviewers analyze the underlying clinical record. According to Medicare’s 1997 Chief Financial Officer’s audit, paying for medically unnecessary care was the most common mistake Medicare made. However, reviewing medical records to make a claim payment determination is costly and burdensome for the Medicare program and the provider.

YOUR RIGHTS AS A PROVIDER

Being selected for a cost report audit or medical review does not necessarily mean that the Medicare program thinks you have done anything wrong. Auditors and reviewers will review your cost reports and claims with open and neutral minds. While contractors are focusing attention on you because of unexpected billing patterns, for example, there may be appropriate and good explanations for those patterns. Only by reviewing information actually on the cost report, claim, and perhaps reviewing supporting information can contractors reach conclusions about whether there is a problem.

You have the right, during any review, to be treated respectfully, courteously and fairly, and to have your questions answered in a timely manner. You also have a right to appeal determinations with which you disagree, so long as such appeals are filed in accordance with regulations governing that process.

How are providers selected for medical necessity reviews?

Providers may be selected for medical review based on several factors. Random reviews are conducted primarily as a way to assess where problems are occurring throughout the system, but also as a general programmatic control. More often, however, providers are selected for medical review on the basis of prior problems or atypical billing patterns. They may also be selected for review because WPS-Medicare is focusing on a particular kind of problem (e.g., errors in billing a type of service) for which they are submitting claims.

What percentage of Medicare Integrity Program Funds is spent on anti-fraud activities?

Approximately 16 percent of MIP funds are spent on anti-fraud activities. WPS-Medicare responds to beneficiary complaints of fraud, develops cases for referral to law enforcement, supports law enforcement in their efforts, and conducts data analysis to identify suspicious billing or service delivery patterns that could be indicative of fraud.

The overwhelming percentage of chiropractors who provide services to Medicare beneficiaries are honest, careful and conscientious. However, there are some who enter the program solely intending to run a scam. Some are drawn into illegal activity by others. There are those who consistently cheat the program by padding lots of bills “a little at a time.” Some desire to participate in the program and receive payments but “deliberately ignore” or “recklessly disregard” problems in their operations that lead to Medicare overpayments.

Why can’t Medicare implement a “one-strike” policy, so that first time errors are dealt with through education?

Most errors are addressed administratively when they are first encountered, by collecting the overpayments identified in the specific cases or claims and engaging in education. However, when the information suggests that the error has resulted in significant losses to the Medicare program, additional corrective action is taken (for example, conducting a postpayment review to determine the amount of overpayments made).

How does CMS make sure providers have input into Medicare rules and program decision?

CMS uses a variety of mechanisms to receive feedback from its providers. At the local level, WPS-Medicare uses a Clinical Advisory Committee on which the WCA has a representative. Proposed rules are issued in the Federal Register and the public has the opportunity to provide comments or suggestions to CMS. Unfortunately, many of the significant rules are developed at CMS headquarters where the chiropractic profession does not have much influence.

We have a lot of policies and procedures but they are unwritten. Should we have them in written form?

bTo paraphrase an old saying: ‘If it is not written down, the policy or procedure does not really exist’. Written policies and procedures allow you to have a check list for your employees and serve as a reference guide when an employee has a question. They can also be invaluable as a training guide for new employees.

Does Medicare look for anything special for its compliance policies and procedures?

Medicare wants the policies and procedures for a compliance program to reflect a code of conduct for your employees so there is an understanding that:

- Health care information will be kept confidential according to the HIPAA standards and requirements.

- Documentation will be kept according to Medicare’s requirements.

- Billing will conform to Medicare policies and procedures.

- Each person will be treated without regard to race, creed or color.

Medicare considers the best policies and procedures to be those that are written using clear and plain language.

What billing or coding procedural violations does Medicare perceive as the biggest risk to a chiropractor?

The following billing and coding problems are those most likely to cause concerns to a chiropractor:

• Billing for services not rendered
• Claims for unnecessary services
• Double billing
• Misuse of provider ID numbers
• Billing for unbundled services
• Failure to use coding modifiers
• Up-coding the level of service

How can a chiropractor minimize the possibility that care will be considered “not medically necessary”?

Complete and legible clinical documentation is the key to substantiating the medical necessity of a patient’s care. The history and exam are vital to establishing the objective basis for the patient’s condition. The assessment and diagnosis are critical support for the patient’s treatment plan. Continuous notes reflecting the progress of the patient help the reviewer understand the need for continuing care. Re-exams are essential to establish the need for long term care, especially for severe conditions.

What concerns does WPS-Medicare have with the way CMS 1500 forms are prepared?

A chiropractor can reduce the risk of a claim review if they:

• Link the ICD-9 code with a history & exam
• Link the diagnosis with a procedure code
• Use modifiers appropriately
• List other insurance coverage

May a chiropractor routinely waive a Medicare patient’s deductible?

No. Out of pocket expense (NOOPE) arrangements are a violation of federal law, state law, and chiropractic examining board rules. If a patient has a genuine financial hardship a chiropractor may not be able to collect their deductible (or co-payment in the case of a group health patient). To avoid the appearance of breaking the NOOPE laws, a chiropractor should document all of the collection activities taken against the patient and any extenuating circumstances that made collecting their deductible impossible.

May a chiropractor ever receive anything of value in exchange for giving another provider a referral?

A chiropractor may never receive anything of value in exchange for referring a patient to another provider, to an attorney, or to another health care facility (such as an MRI facility or a rehabilitation facility). “Anything of value” literally means anything that has any type of value. Should a chiropractor violate this law, he or she could face substantial penalties and the possibility of serving prison time.

May a chiropractor ever pay anyone in exchange for a patient referral?

A chiropractor may never pay anyone for referring a patient to them. Payment means providing anything of value in exchange for the referral. The prohibition against paying for referrals applies to all patients regardless of who is paying for their care (WC, PI, Medicare, MA, Group Health)

What should be the specific job responsibilities for the person in charge of the compliance program?

This person should be responsible for all of the following:

• Monitor the compliance program
• Setup periodic audits
• Update the compliance manual
• Train new staff
• Communicate with the DC
• Correct problems

How quickly should a new employee be given Medicare compliance training?

The sooner a new employee receives Medicare compliance training the less likely they are to make a mistake that requires you to make a refund to Medicare. The best practice is for you to train the staff in their compliance responsibilities as part of the training related to Medicare. If that is not practible, your goal should be to have all employees completely familiar with their compliance responsibilities within 60 days of the date of hire.

Why are staff meetings more effective for solving compliance problems than a memo posted on a bulletin board?

There is nothing wrong with posting memos or reminders on the office bulletin board. In fact, they can be an effective management tool. However, posted memos are an example of one-way communication. Procedures that allow for two-way communication, such as a staff meeting, will accomplish more because your staff will have a better understanding of their responsibilities and will be able to contribute to solutions as problems are discovered. When a staff person is allowed to contribute to a solution, they will be more committed to solving a problem.

Does Medicare expect me to discipline staff members when they make a mistake following Medicare’s procedures?

Medicare does not require you to discipline staff when they make a procedure error; however, having a disciplinary process in place is an excellent way of communicating to Medicare – and your staff – that following procedures is an important responsibility.

When you have a progressive discipline system in place it demonstrates your commitment to your compliance program. Since most mistakes require nothing more than re-training, a conscientious staff person would have nothing to fear from a discipline process. In addition, should you have the unfortunate experience of hiring an individual that deliberately ignores Medicare’s policies and procedures; you will have a method to deal with the performance issues.

What disciplinary steps are a “best practice” for a Medicare compliance program?

The following disciplinary steps are the “ladder approach” recommended by Medicare:

• Oral Warnings
• Written reprimands
• Probation
• Demotion
• Suspension
• Termination
• Referral for prosecution

Remember, it is not necessary to start at the beginning of the “ladder”. The severity of the problem, past performance, and other extenuating circumstance will help you determine what level of discipline is warranted for a particular problem.

We use a third party billing service to bill our Medicare claims. Am I responsible for the billing service’s failure to follow Medicare’s rules?

Unfortunately, you are responsible for all bills sent in your clinic’s name regardless of who did the actual billing. For this reason, you should conduct periodic reviews of your billing service just as if your staff were preparing your claims.

Can my billing service receive my checks for me?

No. Medicare rules require that all checks be sent directly to you. The billing service cannot directly receive Medicare payments.

What is the penalty for a non-participating provider who bills in excess of Medicare’s limiting charge?

Doctors who regularly bill in excess of the limiting charge may be fined up to $10,000 per violation or be excluded from participation in federal health care programs for up to two years.

May I advertise that I provide Medicare or Medicaid services?

Medicare rules specifically prohibit doctors from advertising for the purpose of soliciting Medicare or Medicaid services. The penalty is up to $5,000 per violation.

What is the penalty for chiropractors that bill for adjustments that were never performed?

A chiropractor that knowingly bills for services that were never performed is guilty of fraud punishable by fines and up to 10 years in prison.

How does Medicare define “subluxation”?

For Medicare purposes, subluxation is defined as a motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.

Does Medicare require the subluxation to be documented and, if so, how?

A subluxation may be demonstrated by an x-ray or by physical examination. An x-ray may be used but is no longer required. However, if an x-ray is used, the x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.

If the subluxation is demonstrated by a physical exam, a chiropractor must evaluate the musculoskeletal/nervous system to identify:

• Pain/tenderness evaluated in terms of location, quality, and intensity;
• Asymmetry/misalignment identified on a sectional or segmental level;
• Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
• Tissue, tone changes in the characteristics of contiguous, or associated soft

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under the above physical examination list are required, one of which must be asymmetry/misalignment or range of motion abnormality. The history recorded in the patient record should include the following:

• Symptoms causing the patient to seek treatment;
• Family history if relevant;
• Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
• Mechanism of trauma;
• Quality and character of symptoms/problem;
• Onset, duration, intensity, frequency, location and radiation of symptoms;
• Aggravating or relieving factors; and
• Prior interventions, treatments, medications, secondary complaints.

Is the technique used by a chiropractor to adjust a patient related to the choice of the CMT code used to bill for the service?

The technique utilized by the chiropractor to treat the subluxation is unrelated to the CPT code chosen. For example, a chiropractor may prefer to perform a full spine adjustment or a single vertebra adjustment. The CPT code is not dictated by the chiropractor’s personal technique but by the number of regions manipulated.

What are Medicare’s documentation requirements for the patient’s first visit?

The following are Medicare’s documentation requirements for the patient’s initial visit. The documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. Full and complete history.
2. Description of the present illness including:

• Mechanism of trauma;
• Quality and character of symptoms/problem;
• Onset, duration, intensity, frequency, location, and radiation of symptoms;
• Aggravating or relieving factors;
• Prior interventions, treatments, medications, secondary complaints; and
• Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

3. Evaluation of musculoskeletal/nervous system through physical examination.

4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.

5. Treatment Plan: The treatment plan should include the following:

• Recommended level of care (duration and frequency of visits);
• Specific treatment goals; and
• Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

What are Medicare’s documentation requirements after the initial visit?

The following are Medicare’s documentation requirements for subsequent visits regardless if the subluxation is demonstrated by x-ray or by physical examination:

1. History

• Review of chief complaint;
• Changes since last visit;
• System review if relevant.

2. Physical exam

• Exam of area of spine involved in diagnosis;
• Assessment of change in patient condition since last visit;
• Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

What are the categories of conditions that Medicare recognizes for coverage?

• Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury that is substantiated by x-ray, if necessary, and the first date of treatment and diagnosis are reasonably proximate. The result of chiropractic manipulation is expected to be an improvement in, arrest or retardation of the patient’s condition. This result should be obtained within a reasonable and generally predictable period of time. Some patients with acute conditions may require several weeks of treatment, while others require a much shorter duration of treatment. Initially, services may be more frequent, but Medicare would expect to see a decrease in frequency as a result of the improvement in the patient’s condition.

• Chronic subluxation: A patient’s condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable (no significant change after two or three weeks of treatment) for a given condition, further manipulative treatment is considered maintenance therapy and is not covered.

What appeal options are available when Medicare denies a claim?

If you disagree with a Medicare determination to disallow all or part of your medical claim, you can question the decision through an appeals process. There are several levels of the appeals process:

Informal Reviews The first step is an informal review. The request for a review must be made within six months of the date of the initial determination. Written requests should be sent to the attention of the Informal Review Unit at WPS-Medicare. They must include:

1. A copy of the claim in question, including a complete diagnosis,

2. A copy of the EOMB,

3. Any additional information which may help WPS-Medicare in reviewing the case, such as office notes, and

4. A statement of specific reasons why you feel the original decision was incorrect, and identification of the exact procedures in question.

This information can be submitted on the Medicare Part B Physician/Supplier Review Request form.

When a written review is requested, WPS-Medicare reviewers make informal review decisions based on the information received. You are entitled to only one review, so it is important to include all the information listed above so WPS may make an accurate decision. After the informal review is completed, you will receive notice of the decision if you requested the review and accepted assignment on the claim. In all other cases, the notice is sent to the beneficiary or legal representative. Notices are only sent when part or all of the original decision is upheld. If the services are paid on review, the EOMB is the only notice issued. This review will not be made by the same individual who made the original determination but by another individual.

Requests for fee evaluations or requests to have claims reprocessed because of a change to your fee schedule are not considered review requests. Fee evaluations should be sent to the attention of the Reimbursement Unit; claims adjustments should be sent to the Payment Record Adjustments Unit (PRA).

Claim adjustments include duplicate payments, improper deductible assessment, claims processed under the wrong Medicare number, incorrect provider numbers and billing errors which cause some kind of recoupment.

An informal review may also be requested using the telephone review process. Please have all of the information listed above available at the time of the telephone review request. To request a telephone review call (608) 222-1421.

Provider Telephone Reviews Using the telephone review process instead of the written review appeal process has several potential advantages. It provides you with same day response to your review request. Telephone reviews give the provider and the Medicare review staff an opportunity to discuss the services in question. Telephone reviews reduce paper and mailing costs for the provider as well as contributing towards a paperless review environment.

Provider telephone reviews can be done by two methods. One is the call-in process; the other is the call-out process. For the call-in process, providers can call-in on a direct line to the review unit. The telephone number is (608) 222-1421. The line is open from 9:00 - 12:00 and 1:00 - 3:00, Monday thru Friday. Telephone reviews are also done on a call-out basis. In the call-out process, the Medicare review staff place a call to providers at a set day and time to handle any review requests the provider may have. The call to the provider is usually made by the same review staff member each week. Providers can call (608) 222-1421 and request to be put on the review call-out schedule.

As with written requests, telephone review requests must be made within six months of the date of the initial decision (the date on the Voucher). Most issues can now be reviewed over the telephone. The following ANSI Messages cannot be addressed over the telephone: 5, 11, 13, 16, 17, 19, 21, 22, 23, 28, 31, 42, 46, 49, 50, 52, 58, 111, 117, B6, B11, B16, B17, B18, B19, M12. Beneficiary Telephone Reviews The telephone review process is also available for Medicare beneficiaries. The beneficiary can request a telephone review by calling the Medicare beneficiary toll-free telephone number. Using the telephone review process in place of the written review appeal process has several potential advantages for the beneficiary. For most beneficiaries, it is much easier to make a telephone call than to write a letter requesting a review. The beneficiary has the opportunity to discuss their claim with the Medicare review staff and receive a review decision at the time of the call. The telephone review process is also less costly for the beneficiary than a written request. Telephone reviews save mailing costs and can be done on the toll-free telephone number.

Medicare beneficiaries are encouraged to contact their chiropractor before requesting a written review. The beneficiary should request, from their provider, all pertinent information relating to their claim so that it can be submitted at the time of the review request. Having this information available at the time of the review avoids processing and payment delays for both the beneficiary and the provider.

If your Medicare beneficiaries have questions regarding the telephone review process, they can call the Medicare toll-free beneficiary phone number.

Carrier Hearing If you are dissatisfied with the decision after your claim has been reviewed, you may request a hearing before a Hearing Officer appointed by the carrier. You are entitled to a carrier hearing if:

1. The request for a hearing is filed (in writing) within six months from the date of the informal review notice.

2. The difference between the amount charged and the amount approved is at least $100 (less any portion of the $100 deductible and the 20% coinsurance).

You may combine a number of reviews (or claims) to meet the $100 minimum requirement, provided the carrier hearing is requested within the six month time frame. In order to do this, you must identify the basis for the aggregation since the claims must all be “similar or related services to the same individual” or involve “common issues of law and fact” arising from services furnished to two or more individuals. Claims, which are aggregated for two or more individuals, must be claims for the same item or service, which have been denied for the same reason, and are being appealed for the same reason in each case.

In the request for a carrier hearing, you must explain why you are not satisfied with the decision. You should also include a copy of the claim, the EOMB, relevant office or operative notes, and any additional evidence you feel may have a bearing on the hearing.

In-Person Hearing This is the traditional hearing. It gives the claimant the opportunity to appear to present oral testimony, in addition to written documentation.

Telephone Hearing For claimants who want to present testimony orally, but do not wish to appear, the telephone hearing may be the answer. It can never be substituted for an in-person hearing without the claimant’s consent. Telephone hearings provide a convenient alternative to providers who are under severe time constraints or to beneficiaries who want to testify but do not necessarily want to appear.

On-the-Record Hearing For claimants who do not wish to appear or present oral testimony, but are willing to let the facts speak for themselves, the on-the-record hearing is an alternative. There is no difference in how the hearing official develops and weighs evidence, or in how the decision is reached. It is the least expensive of the alternatives.

All hearings are basically the same in which each decision must be based on the facts developed and applicable program laws, regulations and policies. Under these procedures Medicare requests that you specify the kind of hearing you wish.

What about our Medicare patients that are blind or unable to read. How do they sign their ABN forms?

Patients that are blind, cannot read, cannot read English, or a deaf patient must be given their ABN through an authorized representative of the patient, or the doctor must take other steps to overcome the difficulty of notification. This may include providing notice in the language of the patient (or authorized representative), in Braille, in extra large print, or by getting an interpreter to translate the notice, in accordance with the needs of the patient or authorized representative to act in an informed manner. Once again, the provider is liable for the cost of care if they do not follow these procedures.

If you request an in-person or telephone hearing, one will be scheduled. Meanwhile the Hearing Officer may render a decision based on the evidence in the file. The Hearing Officer will include with the OTR decision a postage-paid, preaddressed postcard for you to return, either confirming that you wish to proceed with the in-person or telephone hearing, or indicating the in-person or telephone hearing is not needed.

What if we do not have our patients sign ABNs?

The ABN is one of the first items Medicare asks for when they conduct a compliance audit. If a chiropractor fails to provide a proper ABN in situations where one is required, WPS-Medicare will find that the chiropractor, not the patient, is liable for the cost of care. That means you will be required to refund Medicare or the patient for every adjustment for which an ABN should have been signed.

If the amount in controversy is $500 or more, the postcard provides for you to indicate plans to proceed directly to the next level of appeal, which is the Administrative Law judge hearing. Remember to return this postcard to WPS-Medicare. In some cases even though an on-the-record (OTR) decision is requested, the Hearing Officer may decide that an in-person or telephone hearing would make a more equitable decision. You will be notified of such a decision and the hearing will be scheduled.

The claimant is responsible for securing all needed evidence to establish the claim, and the Hearing Officer will make every effort to ensure that sufficient evidence is obtained. However, if the claimant is the provider; the hearing officer is not required to develop for additional information. Therefore, it is very important that all supporting evidence (e.g., daily progress notes) is submitted with the initial hearing request. It is also helpful to submit a copy of the EOMB and a copy of the review letter for the claim at issue.

Administrative Law Judge Hearing You may appeal the Carrier Hearing Officer’s decision to an Administrative Law Judge (ALJ) when the amount in controversy is $500 or more. You may combine a number of claims to meet the $500 minimum under the same criteria as for a carrier hearing. They must be similar or related services for the same individual, or involve common issues of law and fact from services for several individuals. Two or more chiropractors, either part of the same practice or not, can aggregate Part B claims to meet the $500 minimum in denials to appeal to the ALJ. Claims can be aggregated as long as they involve the delivery of similar or related services provided to the same individual or involve common issues of law and fact arising from services furnished to two or more individuals.

An ALJ hearing must be requested within 60 days of the date of the Carrier Hearing Officer’s decision. If at least $1000 remains in controversy following the ALJ’s decision, you may request a judicial review before a Federal District Court Judge.

Is Medicare a managed care program and who writes its rules?

Medicare is one of those insurance programs in which you can do everything right and still be told that you are doing things wrong! Created by the United States government to provide for the health care needs of the elderly, Medicare is the largest managed care program in the United States and one of the most administratively complex.

The Centers for Medicare and Medicaid Services (CMS) writes the rules of the program and then selects insurance companies, on a regional basis, to enforce its policies. A piece of information not generally known is that each regional carrier does have some flexibility in the way CMS’s rules are carried out. If you feel that Medicare is treating you unfairly, ask the WCA for assistance.

We moved our office and our Medicare checks stopped coming. Why?

Medicare providers must report all general information changes, including address changes, to the Medicare carrier within 90 days of the effective date of the change. Changes must be reported by completing the appropriate CMS 855 application form. A change in the federal tax ID requires all new forms to be completed and issuance of a new PIN. The Part B forms for revisions are:

• Application for Health Care Providers that will Bill Medicare Carriers (CMS 855B )
• Application for Individual Health Care Practitioners (CMS 855I)

You may obtain a copy of the form at: http: //cms.hhs.gov/forms/   It still must be printed, signed, and mailed to WPS.

When the U.S. Postal Service returns a hardcopy check or remittance advice to WPS due to an incorrect address, CMS requires that WPS flag the provider’s file with a Do Not Forward (DNF) notice. The Provider Enrollment Unit is notified, and future payments, including electronic fund transfers, are stopped until the provider furnishes a new address and that address is verified. All addresses (not just corrections to the “pay to address”) must be verified before WPS can remove the DNF flag and resume paying the provider or supplier. Send the revised form to the attention of the Provider Enrollment at WPS-Medicare, Provider Enrollment Unit, PO Box 1787, Madison, WI 53701-1787.

How long do we have to file Medicare claims?

To be eligible for Medicare reimbursement, claims must be filed within a qualifying time limit. The time limit extends to the end of the calendar year following the year in which a service is provided. (Service provided during October, November, and December is considered provided in the next calendar year.) To summarize, at least 15 months from the date of service are allowed for filing claims.

Examples:

Claims Must

For Service Dates be Filed By
10/01/02 through 9/30/03 12/31/2004
10/01/03 through 9/30/04 12/31/2005

If an assigned claim is submitted more than one year after the date of service, payment to the chiropractor is reduced for that service by 10 percent. The provider cannot bill the patient for this reduction.

Valid claims not filed within the time limits are denied. The provider cannot collect the actual charge for the service from the patient when an assigned claim is denied for late filing. When the provider accepts assignment but fails to submit a valid claim within the filing limit, and the actual charge for the service is $300 or less, the patient may only be charged 20 percent of the actual charge. When the actual charge for the service is over $300, the patient may only be charged 20 percent of the amount that Medicare would have approved for the service.

If national health care becomes a reality, will participating Medicare provider have an advantage?

Under any version of national health care that has ever been discussed, present participating providers for Medicare will have no advantage in being selected to provide care in the new system.

What administrative procedures can help to ease the processing of Medicare claims?

• All new CAs should be completely trained in processing Medicare claims. Since the slightest mistake can result in a claim being rejected, the CA should not submit claims on their own until those claims are found to be completely accurate.

• Stay current on policy changes made by Medicare. They can, and do, make frequent changes in the policies for submitting claims. If you carefully read all of the information mailed to you from the carrier, you will have plenty of time to make the necessary changes in your claims processing procedures.

• Bill for your Medicare services frequently. Some offices have special billing cycles for Medicare claims. When you do this, there is a good chance that you may end up having more claims rejected. This is especially true when policy changes are implemented by the regional Medicare carrier. Faster billing also helps your elderly patients keep track of their claims more easily.

• Your office software should be flexible enough to handle the changing requirements of Medicare. A package which is inflexible may be very expensive to modify. Before you buy a software package, find out what the cost will be to have that software modified when Medicare rules change. It is best to deal with companies who have a history of success in this area and to have service agreements in writing.

• It is best to convert your computer system to one which can bill claims electronically, as soon as possible. Electronic claims submission will soon be the standard for all health care offices. It will offer faster payment and include more information about claims as they are being processed. The equipment necessary to submit claims electronically is not expensive. You will need to add a modem to your computer which will let your computer transmit data across telephone lines. It is also best if your computer is connected to a dedicated telephone line. Trying to share phone lines with a computer and / or a fax machine may save you a few dollars per month on your phone bill, but it will cost you much more as you sort out administrative problems.

I am constantly frustrated in my attempts to discuss problems with Medicare. Am I alone?

You are not alone. Perhaps the most difficult part about working with Medicare is trying to communicate with the regional carrier. Because insurance companies bid for the right to process Medicare claims, they do not have a lot of money to spend on provider support. Because of this, you are likely to spend a lot of time on hold when you call their office. To overcome this inefficiency, make sure your telephone has a speaker attachment. This will make it possible for you to continue your other work, while you are waiting for a claims representative to come on the line.

The second biggest problem can be trying to get a consistent answer from the staff of the carrier. For the most part, this is due to the very high rates of turnover insurance companies have on their staffs. When you are constantly training new staff, you are going to have a lot of staff members who are not properly trained.

If you believe that you are not getting the right answer from the claims representative, you should not hesitate to ask for a supervisor to help you with your problem. If they are telling you that you are not following a policy correctly, ask them to read the policy or to send you a copy. If you are not persistent, you may be forced to repeat the process over and over until you get the correct answer. Some days the only thing which will help you is to remember how fortunate you are to be working in your office instead of theirs.

Must we have our patients sign an “Advance Beneficiary Notice (ABN)?

Yes. Advanced Beneficiary Notice (ABN) are required to be used by all health care providers beginning October 1, 2002.

We used to have our patients sign the Medicare Disclosure form. Now that the Advanced Beneficiary Notice is required, must we also have our patients sign the disclosure form?

No. The Medicare Disclosure form is now obsolete.

May we have the patient sign the ABN after they have received treatment?

No. Medicare requires that a patient sign the ABN before any care is given.

Does the ABN requirement affect both participating and non-participating chiropractors?

Yes. All providers must have patients sign ABNs regardless of their provider status.

Must patients be given copies of each ABN form they sign?

Yes. Medicare’s ABN rules require that a patient be given a copy of each form they sign.

What are Medicare’s treatment guidelines?

The following are Medicare’s treatment guidelines:

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration of subluxation within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as 3 months of treatment but some require very little treatment. In the first several days treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.

Chronic spinal joint condition (e.g., loss of joint mobility or other joint problems) implies, of joints have already “set” and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.

Some chiropractors have been identified as using an “intensive care” concept of treatment. Under this type of treatment plan, so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare is limited to not more than one treatment per day unless documentation of the reasonableness and necessity for additional treatment is submitted with the claim.

Since Medicare patients must be given a copy of each form they sign, can we have the ABN printed on 2-part paper?

Medicare allows you to have the ABN printed in a 2-part format.

Besides filling in the information boxes, may we make any other changes to the ABN?

The only other change that can be made is that Medicare allows you to put your name, and other identifying information including your logo at the top of the form.

Must we list every service we provide on the ABN form?

No. ABNs only apply to chiropractic adjustments since this is the only service covered by Medicare. You may list other services on the form but you are not required to do so.

Can we create our own “Advanced Beneficiary Notice”?

No. To be acceptable, an ABN must be on the approved Medicare Form CMS-R-131, and must be properly completed.

In the information at our convenience?

No. The patient must sign the ABN before receiving any service.

Will using the ABN form be a violation of the HIPAA laws?

WPS-Medicare has assured all providers that the use of ABNs will not run them afoul of the HIPAA sanctions.

The Medicare rules state that ABN forms may not be given on a routine basis. Does this mean that our patients should not sign a form on every visit or that we can not use a single ABN for an entire course of treatment?

The WCA believes that it is necessary for a Medicare patient to have an ABN form signed to cover all adjustments based on WPS-Medicare’s claims processing practices. There are specific exemptions in the law that allow for the routine use of ABNs. The WCA believes that chiropractors qualify for the exemptions based on WPS-Medicare’s inconsistent claims processing practices as follows:

• Patient’s first treatment for a new injury is often denied.
• Patient’s first treatment is often denied while subsequent adjustments are paid
• Patient’s often have care for one injury denied, while care for a second injury is completely paid.
• Patients often have care paid for on an intermittent basis for a single injury.

Under Medicare’s Compliance Program, a provider may not charge a patient for a denied service unless the patient signed an ABN form in advance of the service being rendered. Failure to do so results in a requirement to refund the patient and the provider is exposed to the possibility of further penalties. Compliance activity indicates that WPS-Medicare is requiring large refunds when chiropractors have not had patients sign the required advance notification forms.

Many of our patients are visually impaired. May we expand the ABN form so that it is legal sized?

Yes. While the ABN is designed as a letter-size form; it may be expanded to a legal size form, to allow a provider to increase the size of the customizable box areas and to suit the chiropractor’s particular needs. However, the ABN may only be one page in length and may be modified only in the specified user-customizable sections (the logo area, the “items or services” box, and the “because” box). The standard sections of the ABN may not be modified in any manner, other than increasing the size of the type. If a chiropractor improperly modifies the ABN, they may be liable for the cost of the services listed on the form.

May we use a single ABN to covering an extended course of treatment?

Medicare will allow a single ABN to be signed to cover an extended course of treatment if the ABN identifies all items and services for which the chiropractor believes Medicare will not pay. The ABN must be prepared with an original and at least one copy. The chiropractor must retain the original and give the copy to the patient or authorized representative. You may not use italics or any font that is difficult to read in either the “Items or services’ box or the “Because” box. An Arial or Arial Narrow font, or a similarly readable font, in the font size range of 10 point to 12 point, is recommended. In all cases, both the originals and copies of ABNs must be legible and high-contrast.

What do I do when a patient refuses to sign the ABN form?

A patient cannot properly refuse to sign the ABN and still demand to be treated. If a patient refuses to sign an ABN, the chiropractor should consider not treating the patient. At the time a patient refuses to sign the ABN, the chiropractor, or their staff, should note on the ABN the circumstances of the patient’s refusal and have the ABN witnessed.

What is the proper ways to fill out the ABN form for patients being treated for an acute injury?

For patients being treated for an acute injury:

In the “Items or Services” box of the ABN form:

• List the services (the adjustment is required, other services are optional) and with the time period these services will be provided. Make sure to put a box or line before the item so it can be “y” or “x”.

• Dates of services listed must correspond to the written treatment plan.
• If the treatment plan is changed, a new ABN with the new treatment dates must be signed by the patient.

In the “Because” box of the ABN form:

• List the following reasons. Make sure to put a box or line before the item so it can be “y” or “x”.
• Medicare does not pay for this service because they consider it “not medically necessary”.
• Medicare does not pay for this level of service, this many services, or this length of service.
• Medicare does not pay for this service based on the diagnosis.

What is the proper way to fill out the ABN form for patients receiving maintenance, wellness, or preventative care?

For patients receiving maintenance, wellness, or preventative care:

In the “Items or Services” box of the ABN form:

• List the services (the adjustment is required, other services are optional) and with the time period these services will be provided. Make sure to put a box or line before the item so it can be “y” or “x”.
• Dates of services listed must correspond to the written treatment plan.
• One year is the limit for use of a single ABN for an extended course of treatment; if the course of treatment extends beyond one year, a new ABN is required for the remainder of the course of treatment.

In the “Because” box of the ABN form:

• List the following reasons. Make sure to put a box or line before the item so it can be “y” or “x”.
• Medicare does not pay for this service because they consider it “not medically necessary”.
• Medicare does not pay for this level of service, this many services, or this length of service.
• Medicare does not pay for this service based on the diagnosis.

What is the proper way to fill out the ABN form when patients suffer an acute injury while they are being treated for maintenance care?

Because the patient suffered an acute injury while receiving maintenance, wellness, or preventative care a new ABN must be signed by the patient reflecting the different treatment schedule.

In the “Items or Services” box of the ABN:

• List the services (the adjustment is required, other services are optional) and with the time period these services will be provided. Make sure to put a box or line before the item so it can be “y” or “x”.
• Dates of services for treating the acute injury must correspond to the written treatment plan.
• If the treatment plan is changed, a new ABN with the new treatment dates must be signed by the patient.
• When the acute treatment is completed, the patient must sign a new ABN for continued maintenance care.

In the “Because” box of the ABN:

• List the following reasons. Make sure to put a box or line before the item so it can be “y” or “x”.
• Medicare does not pay for this service because they consider it “not medically necessary”.
• Medicare does not pay for this level of service, this many services, or this length of service.
• Medicare does not pay for this service based on the diagnosis.

What are my options for billing Medical Assistance for Personal Injury Cases?

A chiropractor that treats a Medical Assistance patient that has been injured in an auto accident or other personal injury has two options to obtain reimbursement for their care. The first is to bill the liability carrier. The second is to bill Medicaid for the services.

The obvious reason to bill a liability carrier is that you may receive a greater payment from the liability settlement than you would from Medicaid. There are risks, however, when billing a liability carrier. The first is that several years may elapse between the date of the accident and the settlement of the resulting liability claim. This delay in payment may put you past the deadline for filing with Medicaid. The second is that when settlement does occur, there may or may not be enough money to reimburse all of the services you have provided.

When you provide care to an accident victim, you need to make one of two possible initial decisions:

• Refrain from billing Medicaid and seek payment from the liability settlement or from payment of medical benefits under a liability policy. However, if the 365-day time period for billing Wisconsin Medicaid expires, neither Medicaid not the patient may be billed if the liability claim proves worthless or if the settlement is insufficient to fully cover your charges.

• Bill Wisconsin Medicaid to receive immediate payment. Providers are required to check the appropriate accident reporting boxes on the HCFA 1500 form. Failure to check the appropriate boxes on the HCFA 1500 form is considered fraud and may subject you to criminal and civil penalties. If the patient is covered by commercial health insurance, relevant prior insurance billing requirements still apply.

If you select the second option you may not seek further payment in any liability settlement that may follow even if you refund the money Medicaid has paid you. Refunding Medicaid and then seeking payment from a settlement may constitute a felony. Wisconsin Medicaid retains the sole right to recover from the settlement.

Medicaid rationale for this policy is based on a longstanding opinion from the Attorney General. The policy applies to all health care providers.

Can I enroll in Medicare before I receive my chiropractic license?

Unfortunately, no. One of the items on the Medicare application is a request for your license number. If a provider were allowed to apply before obtaining a license, Medicare would have no way of verifying who was authorized to provide services.

Are Medicare providers allowed to waive Medicare Coinsurance?

Coinsurance is the amount that Medicare will not pay; the beneficiary or the beneficiary’s supplemental insurance company is responsible for paying the coinsurance to the doctor.

Coinsurance amounts are generally 20% of the Medicare fee schedule. Chiropractors must collect the unmet coinsurance from the beneficiary. Consistently waiving the coinsurance may be interpreted as program abuse by Medicare. If a beneficiary is unable to pay the coinsurance, you should ask the patient to sign a waiver that explains the financial hardship. If no waiver is signed, the beneficiary’s records should reflect normal/reasonable attempts to collect before the charge is written off.

Are Medicare providers allowed to waive Medicare deductibles?

Like most insurance plans, Medicare has deductibles applicable to covered services that must be satisfied before the carrier pays.

Chiropractors must collect the unmet deductible from the beneficiary. Consistently waiving the deductible may be interpreted as program abuse by Medicare. If a beneficiary is unable to pay the deductible, you should ask the patient to sign a waiver that explains the financial hardship. If no waiver is signed, the beneficiary’s records should reflect normal/reasonable attempts to collect before the charge is written off. Normal collection attempts mean that you must apply the same collection efforts against a Medicare patient that you would apply to a non-Medicare patient.

Do the various compliance program guidance’s issued by the Office of the Inspector General (OIG) represent the ultimate compliance program?

The OIG periodically issues compliance guidelines for chiropractic and other health care provider’s practices. For example, the OIG warned providers about the risks of getting involved with Comprehensive Outpatient Facilities (CORFs). The guidelines represent the OIG’s suggestions for how you can best establish internal controls and monitoring to correct and prevent fraudulent activities. By no means should the contents of these guidance’s be viewed as an exclusive discussion of the advisable elements of a compliance program. There is no single “best” compliance program.

We appealed a claim denial and lost. What are our options?

If, after a review, you are dissatisfied with the outcome and the amount in dispute (the difference between the billed amount and the Medicare allowed amount, less any outstanding deductible) is $100 or more, you may request a hearing. The claim can be added to previous or subsequent claims with which you or the patient is dissatisfied to meet the requirement, as long as the appeal is filed timely for all claims at issue (within 6 months from the date of the initial claim determination) and the claims are properly at the level of appeal requested.

Medicare has overpaid us on a claim. Are we required to refund Medicare immediately or do we wait for Medicare to notify us?

If Medicare overpays in error, the overpayment should be refunded as soon as possible without waiting for Medicare to send a letter. WPS-Medicare can provide the address of where to mail the refund. The following must be included with the refund:

• The provider number
• The patient’s Medicare number
• A brief description of the reason for the refund
• A copy of the remittance notice highlighting the claim(s) at issue
• A check for the overpaid amount

How are post-payment reviews conducted?

Postpayment review can be done on a claim by claim review, or by using statistically valid random samples. The advantage of sampling is that an underpayment or overpayment (if one exists) can be estimated without requesting all records on all claims from a provider. Medicare has established minimum sampling requirements to ensure that samples are drawn appropriately and an acceptable level of precision is obtained. Among the safeguards they have established for sampling is the balancing, or “netting out” of overpayments with underpayments; inclusion of claims denied as well as claims paid in the universe from which the sample is drawn; use of the lowest estimate of the overpayment; and a requirement for WPS-Medicare to consult with statistical experts in developing the sampling method. Providers undergoing review have the right to appeal, not only the individual determinations of the claims in the sample, but the sampling method.

Can I be punished with jail or fines for making innocent mistakes?

The Government’s primary enforcement tool, the civil False Claims Act (FCA), covers only offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard of the truth or falsity of the claim, or deliberate ignorance of the truth or falsity of the claim. The FCA simply does not cover mistakes, errors or negligence. The other major civil remedy available to the Federal Government, the Civil Monetary Penalties Law, has exactly the same standard of proof. Medicare is mindful of the difference between innocent errors and negligence (erroneous claims) on the one hand, and reckless or intentional conduct (fraudulent claims) on the other.

What are the benefits of implementing a Medicare compliance program?

Chiropractors that implement a compliance program have taken a significant step toward assuring that they are not submitting false or inaccurate claims to Government and private payers. Compliance programs make good business sense; they may help a provider fulfill its fundamental mission of providing quality services as well as assisting in identifying weaknesses in internal systems and management. Other benefits are:

• Effective internal procedures
• Improved documentation
• Improved employee education
• Reduction in claim denials
• Avoidance of potential liability
• Reduced exposure to penalties

Can I pay my billing service based on a percentage of the revenue they bill?

Paying your billing service on a percentage basis raises a major red flag for Medicare. Since the size of the claim is not related to the cost of billing the service, paying for services on a percentage basis makes it appear that fraudulent billing could occur in order to increase the payment to the doctor and/or the billing service. To avoid the inevitable hassle with this billing arrangement, a more tradition method (i.e., a fixed fee per billing cycle or a fixed fee for each claim billed) of paying for your billing service should be used.

What are the seven basic elements of a Medicare Compliance Program?

The seven basic elements of a Medicare compliance program are:

• Written policies and procedures
• Assigning responsibility for compliance
• Training on ethics, policies and procedures
• Internal monitoring and auditing
• Develop lines of communication
• Enforce disciplinary standards

How does Medicare define “maintenance care”?

Medicare defines maintenance care as a treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition is not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.

What is the best internal audit tool I can use to let me know when I might have a problem with Medicare?

Your best weapon against Medicare audits is to be proactive when you discover mistakes in your Medicare practices. For example, you can ask your staff to show you every claim that Medicare rejects for any reason. This will give you an idea as to how your billing and coding staff are performing at their jobs. As mistakes are encountered, you have the opportunity to refine your policies and procedures, or to re-train your employees.

In addition to tracking current problems, you should also do periodic audits on a set schedule of all of your billing and coding activities. This audit will help you spot internal problems that may not be easy for Medicare to detect, but would be devastating if discovered by Medicare during an audit. Your internal review should assess if you are using proper ICD-9 codes and CPT coding, verify that your patients sign disclaimer forms, and insure that your documentation is being kept in a manner that satisfies state law and Medicare requirements.

The best internal audits document the results of the audit, both good and bad, and list the steps that will be taken to correct any errors that were found. A repeat audit should focus on problem areas to insure they were properly resolved. Staff that made the errors should be counseled or re-trained as necessary.

I’m looking at my claims to make sure I am billing correctly. Sometimes I find that Medicare has overpaid me. What do I do?

You must repay any overpayments to Medicare. Often these can be handled administratively by contacting WPS-Medicare. They may be able to offset against future payments or can deposit a check you provide them. If you believe fraud has been involved, you should alert the U.S. Department of Health and Human Services’ Office of Inspector General. In order to learn about the OIG’s Self Disclosure Protocol, please see the descriptive federal register publication at the following website: http://oig.hhs.gov/fraud/selfdisclosure.html#1.htm

I plan on delegating the responsibility for our Medicare compliance program to a member of my staff. What attributes should this person have?

The staff person responsible for the Medicare compliance program should be a person who is detail-oriented, is experienced in billing and coding and is an effective communicator. This last point is perhaps the most important. If the staff person determines that another staff member needs to be re-trained, or that the doctor needs to implement a new procedure, this person must be respected enough so that the doctor will follow the advice that is offered. If the advice is not followed, the individual will not be able to run the compliance program effectively.

We have just received a notice from Medicare that indicates we have made number billing errors. Their notice tells us that we may be subjected to penalties. Is their threat about penalties serious?

The Medicare penalties for non-compliance are very serious. They can involve major fines and the potential for jail terms. The fines are not assessed on a per patient basis, but rather on a per service basis, and they can add up very quickly. If you should ever receive notice that you have done something improper, contact your regional carrier immediately. Make sure you know exactly how to solve the problem so you are not assessed a fine or pennalty.

What are Medicare’s guidelines for establishing the “medical necessity” of chiropractic care?

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

Symptoms are usually related directly to specific anatomic spine areas. Occasionally symptoms are more generalized and associated with several adjacent anatomic sites of subluxation. In such cases, the symptoms involving body structures should relate to the areas of subluxation in the documentation.

What is the purpose of the ABN?

The ABN is a written notice a chiropractor gives to a Medicare patient before an adjustment is given when the chiropractor believes that Medicare probably or certainly will not pay for some or all of a patient’s adjustments on the basis that the care was not “medically reasonable or necessary”. This would include maintenance, preventative or wellness care.

Medicare believes that the ABN allows a patient to make an informed consumer decision whether or not to receive the care for which he/she may have to pay out of pocket or through other insurance. In addition, the ABN allows the patient to better participate in his/her own health care treatment decisions by making informed consumer decisions.

Is the diagnosis of “pain” sufficient to establish the medical necessity of care?

The mere statement or diagnosis of “pain” is not sufficient to support medical necessity for the treatments. The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s). The need for an extensive, prolonged course of treatment should be appropriate to the reported procedural code(s) and must be clearly documented in the medical record.