MSCA Insurance Update: Medicare
Most of you may already be aware, on September 5, 2007, the Centers for Medicare & Medicaid Services (CMS) announced that the Wisconsin Physicians Service Insurance Corporation (WPS) had been awarded the Medicare contract to provide Part A and Part B administrative services for the states of Iowa, Kansas, Missouri and Nebraska.
In an effort to provide you with more details about the Wisconsin Physicians Service, and their plans for implementation, here is a link to their website (below). It has implementation information, dates, contact information and more. This link will also be available on the MSCA website at www.mscainfo.com .
Click Here: http://www.wpsmedicare.com/mac/
THE MSCA INSURANCE COMMITTEE IS TRYING TO COMPILE A FULL LIST OF ALL MISSOURI CHIROPRACTORS WHO HAVE EITHER BEEN TERMINATED OR PUT ON PERFORMANCE IMPROVEMENT AGREEMENTS WITH ACN.
PLEASE, EMAIL THE NAMES TO: freihaut@ruralcom.net
Addressing Misinformation Regarding Chiropractic Services and Medicare
Reference: MLN: SE0749
Published Online: 12/17/2007
Provider Types Affected
Providers submitting claims to Medicare contractors (carriers, and/or Part A/Part B Medicare Administrative Contractors (A/B MACs)) for Chiropractic services provided to Medicare beneficiaries
Provider Action Needed
This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to correct misinformation in the chiropractic community relating to Medicare and its regulations as they relate to chiropractic services. This article is informational only and represents no changes to existing Medicare policy.
Background
In order to correct misinformation about Medicare and its regulations which exist in the chiropractic community, the American Chiropractic Association (ACA) works to check the validity of all claims and provide accurate information based on the Medicare manual system maintained by CMS, as well as information in regulatory and statutory language. CMS is providing this special edition article which it hopes will clarify certain issues, around which there may be some confusion. The specific issues being addressed are:
MISINFORMATION #1: There is a 12 visit cap or limit for chiropractic services.
Correction: There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5. (This manual is available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS website.)
There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.
The Social Security Act (Section 1862 (a)(1); see http://www.ssa.gov/OP_Home/ssact/title18/1862.htm on the Internet) provides that Medicare will only pay for items or services it determines to be "reasonable and necessary," and if those items or services can be shown to be "reasonable and necessary," then those items or services are covered and will be paid by Medicare.
MISINFORMATION #2: If you are a non-participating (non-par) provider, you do not have to worry about billing Medicare
Correction: Being non-par does not mean you don’t have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties.
A non-par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.
It is important to note that non-par providers may choose to accept assignment, therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.
Whether or not a non-par provider chooses to accept assignment on all claims or on a claim-by-claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.
You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf on the CMS website. The form contains important information regarding the participation process and the annual opportunity you have to make or change your participation decision.
Additional information is available in the Medicare Benefit Policy Manual (Chapter 15; Covered Medical and Other Health Services) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS website and the Medicare Claims Processing Manual (Chapter 12; Physician/Non-physician Practitioners) at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf on the CMS website.
MISINFORMATION #3: If you are a non-participating (non-par) provider, you will never be audited nor have claims reviewed, etc.
Correction: Any Medicare claim submitted can be audited/reviewed; the non-participating (non-par) or participating (par) status of the physician does not affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and also to identify billing errors so providers and their billing staff can be alerted of errors and educated on how to avoid future errors. Correct coverage, reimbursement, and billing requirements are readily available to assist you in understanding Medicare requirements. This information is in Medicare manuals that are at http://www.cms.hhs.gov/Manuals/ on the CMS website. In addition, an excellent way to stay informed about changes to Medicare billing and coverage requirements is to monitor MLN Matters articles, such as this one, which are available at http://www.cms.hhs.gov/MLNMattersArticles/ on the same site.
MISINFORMATION #4: You can opt out of Medicare
Correction: Opting out of Medicare is not an option for Doctors of Chiropractic. Note that opting out and being non-participating are not the same things. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out.
For further discussions of the Medicare "opt out" provision, see the Medicare Benefits Policy Manual (Chapter 15, Section 40; Definition of Physician/Practitioner) at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf on the CMS website.
MISINFORMATION #5: You should get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits.
Correction: The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service. Should the beneficiary decide to receive the service, you must then submit a claim to Medicare even though you expect the beneficiary to pay and you expect that Medicare will deny the claim.
For further information, see the Medicare Claims Processing Manual (Chapter 30) at http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf and the Medicare Benefits Policy Manual (Chapter 15) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS website. Also see "What Doctors Need to Know about the Advance Beneficiary Notice (ABN)" at http://www.cms.hhs.gov/MLNProducts/downloads/ABN_READERS.pdf on the CMS website.
MISINFORMATION #6: Maintenance care is not a covered service under Medicare.
Correction: Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not medically reasonable and necessary and therefore not reimburseable by Medicare. Acute, chronic, and maintenance adjustments are all "covered" services, but only acute and chronic services are considered active care and may, therefore, be reimbursable. Maintenance therapy is defined (per Chapter 15, Section 30.5.B. of the Medicare Benefits Policy Manual)) 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. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.
See MM3449 (Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3449.pdf on the CMS website. This article contains important information on completing claims and how to identify acute and chronic adjustments as opposed to maintenance adjustments. The article also recommends you consider issuing an ABN to the Medicare beneficiary when you provide maintenance services. Additional details are available in the Medicare Benefits Policy Manual, Chapter 15, Section 30.5 (Chiropractor’s Services) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS website.
MISINFORMATION #7: Non-par providers do not have the same documentation requirements as par providers.
Correction: Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements.
Specific details regarding documentation are in the Medicare Benefit Policy Manual (Chapter 15, Sections 30.5 and 240) at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf on the CMS website. Also, see the Medicare Claims Processing Manual (Chapter 12, Section 220) at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdfon the CMS website.
Additional Information
If you have any questions regarding chiropractic issues and Medicare, please contact your Medicare carrier or A/B MAC at their toll-free number, which may be found on the CMS web site at:
http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip
Sample Electronic Filing Exemption Letter
This letter is for demonstrative purposes only and members should consult their legal counsel as individual situations may vary.
Lawsuit Filed Against UHC/ACN
On January 4, 2006, several Missouri Chiropractors joined to file a class action lawsuit against United Healthcare Corporation (UHC) and American Chiropractic Network (ACN) in the Western Division of the federal court of the United States. The lawsuit alleges UHC/ACN created a way to cut healthcare costs that affects the quality of healthcare available to patients. UHC/ACN profiles the doctors and uses these profiles to determine the level of care patients need. They send out notification to doctors that places them on probation, and gives them six (6) months to improve or face possible termination from the UHC network. Many doctors across the country have received these notifications called Performance Improvement Agreements, and many have been terminated.
The performance Improvement Agreements gave doctors criteria they should fall under, according to ACN. It limits the doctors to an average patient visit number not to exceed 6.2 visits per 6 months. Some states have reported these averages were 2.7 patient visits per year. There are approximately 29,000 providers in the ACN network.
The Missouri Division of Insurance (MDOI) is also looking into the matter after many complaints have been filed with them concerning ACN and UHC.
Medicare Survey
Although you may already be aware of the CMS Provider Satisfaction Survey, and may even have subscribed to listserv, we want to reiterate the importance to complete the Survey if you are selected.
Centers for Medicare & Medicaid Services (CMS) Seeks Provider Input on Satisfaction with Medicare Fee-for-Service Contactor Services
Reference: Medlearn Matters Number: SE0602
The Centers for Medicare & Medicaid Services (CMS) would like to provide a channel for you to voice your opinions about the services you receive from your Fee-for-Service (FFS) Contractors. The Medicare Contractor Provider Satisfaction Survey (MCPSS) is designed to garner quantifiable data on provider satisfaction with the performance of FFS contractors. The MCPSS is one of the tools CMS will use to carry out the measurement of provider satisfaction levels, a requirement of the Medicare Modernization Act (MMA). Specifically, the survey will enable CMS to gauge provider satisfaction with key services performed by the 42 contractors that process and pay the more than $280 billion in Medicare claims each year. Those Medicare contractors will use the results to improve services. CMS will use the results to improve its oversight of and increase the efficiency of the administration of the Meidcare program. Be alert for a notification packet in the mail. If you are selected and receive the notification packet, please take the time to complete and submit your survey responses as soon as possible. The data collection period for the pilot will continue through the end of April.
http://www.momedicare.com/provider/viewarticle.aspx?articleid=2733
Make Complaints to Department of Insurance
When you feel an insurance company has violated your patient's right to chiropractic care, or your fair and timely reimbursement, there is a place to file your complaint. The Department of Insurance provides forms for patient and provider complaints. As a convenience, the MSCA is adding a link to its web page, on the "Forms/Links" page, for easy access to the DOI web page and complaint form.
http://insurance.mo.gov/consumer/complaints/
Providers can file complaints using this form:
http://insurance.mo.gov/industry/forms/provComplaint.doc
Insurance Committee Report
by Margaret Freihaut, DC
Chairperson
BLUE CROSS BLUE SHIELD - BC/BS sent notices to us that, as of April 15, our reimbursement for some of the services we provide will be reduced by approximately 20 percent. I have been in contact with representatives for Blue Cross Blue Shield, and they said the decision was made, in part, to keep up with their competitors, and was based upon a study performed over the last year. We are hoping to set up a meeting with them to discuss how chiropractic saves healthcare dollars, and to discuss the concerns from both sides.
MEDICARE - I will be going to Washington, DC, for the ACA National Legislative Conference annual meeting for CAC representatives throughout the United States. This will be the third year of my attendance. CAC is a government advisory committee that meets quarterly to review medical policies, and to keep the professions abreast of Medicare changes. The conference this year will concentrate on Medicare documentation. If you have Medicare questions, feel free to call me, or email me at freihaut@ruralcom.net.
Remember to apply for your national ID numbers. They will be required next year. Medicare reduced our fees for 2006, and has since rescinded that decision and is raising our fees. For more information, you can go to www.momedicare.com.
ACN/UHC - As most of you know, a class action suit was filed on behalf of some Missouri chiropractors. Our doctors in Missouri have filed complaints to the Division of Insurance which is looking into their practices. The Missouri State Board of Chiropractic Examiners has sent a letter to ACN about their improper reviews. The ACA is sending a letter to our Division of Insurance discussing the many states and agencies that are looking into the practices of ACN and UHC. The ACA is working with many different states to address the many complaints their members are making against UHC and ACN. |
