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Medicare: The ABC’s of Getting Paid Correctly the

First Time

Abbie Miller, MCS-P, CCCA

CLASS NOTES

Please pick up a lecture handout located in the back of the room. In order to retrieve an expandable

version of our class notes, you will need the access code located at the end of your lecture handout. You WILL NOT be able to access the expanded version of

these notes without this code.

If you are looking for diplomate hours, your badge must be stamped at the registration desk with a red ACBN stamp. Your hours will be automatically credited with your required class scan at the door to pertaining classes.

Programs that mention or promote specific products, services or companies are not eligible for approval to offer continuing education credits in the State of FL. Today’s speaker has agreed to not mention specific

products, services, or companies in this presentation. If this agreement is violated, please report to the FCA verbally, or via the feedback form in your convention

packet / show guide.

Per the rules of the Florida Board of Chiropractic Medicine, each attendee is required to have his/her badge scanned 4

times a day – with Photo ID – at the “attendance desk”regardless of which classes you attend.

Thursday12:30pm – 2pm4:30pm – 5:30p

Friday7:00am – 9am11am – 12:30pm12:45pm – 2pm4:30pm – 5:30pm

Saturday7:30am – 9am11am – 12:30pm12:45pm – 2pm4:30pm – 6pm

Sunday7:30am – 9am11:45am – 12:30pm2:30pm – 3pm4:30pm – 5pm

Attendance Desk Hours

Network: Sheraton_Conference

Access Code: Not Required

Medicare Billing “Rules”

•Medicare has very specific rules to follow

•Their requirements may be different from other carriers

•Due to compliance risks, knowledge of these rules is critical

What We’ll Cover

•Medicare billing nuances

•Coding and modifier usage

•Timely filing

•Rules that outline who you can bill

Billing Nuances for Medicare Requirements to Treat Medicare Patients

•Providers must be registered with their Medicare carriers•Must choose participating or non-participating•Maintain status, must re-verify•May not “opt-out” to avoid billing Medicare

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Provider Numbers and Medicare

•NPI

•PTAN

•UPIN

•TAX ID or EIN

Entering Provider Information

•Box 31 – Physician’s Signature

•Box 32 – Service Facility Information

•Box 33 – Provider of Service Information

Getting to know your MAC

Where in the World is my MAC?

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What Does a MAC Do?

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries

What Does a MAC Do?

CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

What Does a MAC Do?

•MACs perform many activities including:• Process Medicare FFS

claims• Make and account for

Medicare FFS payments• Enroll providers in the

Medicare FFS program• Handle provider

reimbursement services and audit institutional provider cost reports

• Handle redetermination requests (1st stage appeals process)

• Respond to provider inquiries

• Educate providers about Medicare FFS billing requirements

• Establish local coverage determinations (LCD’s)

• Review medical records for selected claims

• Coordinate with CMS and other FFS contractors

Like Any Other Government Contrator

DME Handled by Different MACDo You Know Your Carrier?

•What can you do on your carrier’s website?• Look up fee

schedules• Review policy and

procedure• Find your LCD• Sign up for bulletin

board notices•Get training•Use the IVR

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Look Up Fee Scheduleswww.fcso.com

Largely a Self-Serve Process

Look Up for 98940 2017 Fee Schedule

Chiropractic Lookups Specific Training-Basic and Chiropractic

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Verification and the IVR Partner with Your MAC

•Not automatically the “bad guy”

•Know how to interact with the MAC

•Learn who in provider services can help you

CMS Requirements

•Onset Date for Medicare

•Use Box 14

•Date of treatment for this episode

Other Special Requirements

•Billing x-ray codes for denial•Box 17 - Ordering physician

•Box 17b - Ordering physician’s NPI

Carrier Required Data

•How and when you documented presence of subluxation, x-ray or PART exam

•Box 19 may be used to report dates on claim form

•Always support this in documentation

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Medicare Advantage: Part C

•Depends on your participation•Don’t risk becoming a deemed provider•You set your policy and fee for this IF you are not involved with any plans•Treat the patient like a cash patient

Secondary and Supplemental Insurance

• If the secondary pays for excluded services

• If the secondary only pays for allowable charges and fees

•Bill your fees as you would for Medicare

•Allowable vs. Limiting Fee for CMT

When Medicare is Secondary Payer

• Auto Accidents/No-Fault and other injuries• If Medicare is involved, you

may be limited to the Medicare Fee Schedule• If primary pays more than

Medicare would have, Medicare will not pay up to ACTUAL fee• Very confusing, no written

references• Attorneys may cite this

rule…ASK FOR A REFERENCE!

Coding and Billing Rules

Chiropractic Services CMS Basics

•CPT Codes paid by CMS to Chiropractors…•98940 (Chiropractic Manipulation)•98941 (Chiropractic Manipulation)•98942 (Chiropractic Manipulation)

•CPT codes not paid by CMS to Chiropractors…•98943 (Chiropractic Manipulation / Extra spinal)•All Exams, Therapies, X-rays, DME, Etc.

Procedure Codes on Claims

•Box 24

Date

CPT Code

Diagnosis Pointer

Charge

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Special Code Restrictions In Medicare

•97010 – Bundled into CMT code, not billable to secondary/supplements

•97014 – not recognized, replaced by HCPCS code G0283

Diagnosis Driven

•Medicare covers only treatment by manual manipulation for a subluxation of the spine

•Local carrier determines how you report

Diagnosis Driven

•Supporting neuromusculoskeletal diagnosis•Supporting diagnosis list available from carrier•Two diagnoses for each segmental level•At least two diagnoses on a claim

Florida’s First Coast LCD

Diagnosis PairingModifiers

•Use in Box 24D

•Multiples may be used

•“Pricing” modifiers in first place

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Modifiers Used with Spinal CMTs Modifiers Used with Non-Spinal CMTs

Remittance Codes Final Billing Rules

Crosswalk Feature

•Patients must request this function from Secondary/Supplement

• Secondary Supplement sends info on patient to Medicare

•Medicare sends processed claim information to Secondary/Supplement

Indicating Other Insurance On Claim

•Box 11 D “Yes”

•Box 9 – All information matching the information received from secondary/supplement (should match HIC card from secondary/supplement)

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Verifying Crosswalk Claims

•EOMB has code -definition states “claim information transmitted to …..”

•Patient can verify with Medicare

•Verify on some carriers’ provider websites

Medicare Timely Filing Guidelines

Poor Morris Medicare!

• Medicare is highly regulated

• How you deal with Medicare patients is highly scrutinized

• Make sure that “helping out poor Morris Medicare” doesn’t put you, your license, and your practice at risk

You Must Bill Medicare

• When a Medicare patient receives coverable, AT modifier-worthy care, the doctor must bill Medicare.

• When the patient is receiving maintenance care, s/he can elect through ABN whether it is to be submitted.

• Non-covered care MAY have to be submitted as well.

Medicare Patient Rights Rule

• You must bill when they ask you to, even for non-covered services.

• Regardless of your participation level, the patient decides whether you bill Medicare.

• They can change their minds and you must comply.

The Three Most

Important Considerations

• You must CHARGE correctly…use the correct fee schedule

• You must BILL it correctly…use the right fee whether billing patient OR carrier

• You can COLLECT according to your policies

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Initial Visit

Exam: $120

X-Rays: $130

CMT: $6597014: $35

Total: $350

Routine Visit

CMT $65

97110: $50

97014: $3597012: $35

Total: $185

Initial Visit

Exam: $95

X-Rays: $75

CMT: $3597014: $15

Total: $220

Routine Visit

CMT $35

97110: $30

97014: $1597012: $15

Total: $95

98940: $25.15

98941: $34.86

98942: $42.75

100% Poverty: 75% Discount

125% Poverty: 50% Discount

150% Poverty: 25% Discount

Charges:Participating

Providers• For (AT) Spinal CMT Codes

Onlyo May submit full fee and write-

off down to allowable feeo May submit allowable fee

Actual Fee: 98940 = $40 Allowable Fee: 98940 = $25 Medicare pays 80% = $20 Coinsurance = $5 Write Off = $15

Charges: Nonparticipating

Providers

• For (AT) Spinal CMT Codes Onlyo Must charge and submit

limiting chargeo Equal to 115% of fee

scheduleo Will reduce to non-par

fee if taking assignment on an individual basis

Charges: Statutorily

Excluded Services

• Medicare patients must be charged your ACTUAL fee for the services they pay for out-of-pocket

• If they qualify for a discount due to another program available in your office, they can be charged that fee

You Have Options!

• Simple and legal discounts for members of a Discount Medical Plan Organization

• Legitimate and verified financial hardship

• Different fees when providing Maintenance Care vs. Active Treatment

• Internal policies on collections and payment plans

But, I Want to Give Medicare Patients a Break on Fees!

• Office of Inspector General has been clear about this

• Never routine, never advertised, avoid inducement

• Look for legal and clean but simple ways to have your cake and eat it too

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We Recommend ChiroHealthUSA

• Membership discount plan

• Used for statutorily non-covered services

• No submission to insurance

• You set your office fee for all patients

• Can be used for incidentally non-covered services (maintenance CMT)

Initial Visit

Exam: $120

X-Rays: $130

CMT: $6597014: $35

Total: $350

Routine Visit

CMT $65

97110: $50

97014: $3597012: $35

Total: $185

Initial Visit

Capped Fee: $150

Or 20% Discount

Routine Visit

Capped Fee: $65

Or 20% Discount

Modalities: $10

Procedures: $20

100% Poverty: 75% Discount

125% Poverty: 50% Discount

150% Poverty: 25% Discount

Re-Exams: $25

Each Film: $15

Simple, Clean and Legal

• Do you ever NOT recommend therapy because you know the patient has to pay?

• Would the patient get more complete health care if financial concerns were removed?

• They qualify for the discounted, network-based fee schedule that YOU set.

Many Medicare Patient Legitimately Need Help

Clear Understanding of

Hardship and Discounted Fees

• Your hardship agreement can co-exist with other fee schedules.

• You must set the standard up front, have qualifying factors, and verify eligibility.

• Utilize a standardized form and system

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Mistakes and Blunders

• What may NOT be financial hardship?

o No insurance

o High deductible

o I don’t wanna pay that much

o My other doctor didn’t charge my copays

o Pulse and a spine

Co-Pay or Deductible Waivers for Hardship--Medicare

• The waiver is not offered as part of any advertisement or solicitation;

• Waivers are not routinely offered to patients;

• The waiver occurs after determining in good faith that the individual is in financial need;

• The waiver occurs after reasonable collection efforts have failed.

Collecting at Time of Service

• It’s OK to collect 20% co-pay or known deductible at TOS

• If service is denied, you must refund to patient OR you must appeal

• Medicare IVR can let you know if deductible is met for the year

• Always based on allowable amount if participating

Treating and Billing Family Members

Appeals At a GlanceWays to Win With Medicare

•Learn the rules•Create policy and procedures•Send only clean claims•Appeal any denials•Begin reporting Physician Quality Reporting System codes (PQRS)•Clean up Active vs. Maintenance patients•Master documentation requirements

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