MSCA Insurance Explanation
MSCA Insurance Alert!
We now know the results of the WPS SS Probe Review....
Planned Widespread Chiropractic Comparative Billing Report (CBR) Educational letters to be sent to Chiropractic Providers in J5 Jurisdiction
Chiropractic services remain a focus for the FY2012 Medical Review Strategy. Analysis of our errors for claims submitted 01/01/10 through 12/31/10 demonstrated there were 22 CERT errors for chiropractic services. Insufficient documentation made up 64 % of the CERT errors for chiropractic services in this time frame. Medically unnecessary services made up 27% of the CERT errors for chiropractic services in this time frame. Analysis of the results revealed the documentation did not support the requirements of the policy, the medical necessity of the service, and/or active corrective treatment.
Medical Review recently completed a series of Postpayment Probe Reviews of codes 98940, 98941, and 98942 billed with the AT modifier, which identified the following issue(s) in the jurisdiction:
- 55.87% did not meet the Medicare Coverage criteria which includes documentation did not support the use of the AT modifier and were deemed maintenance or documentation did not support all of the policy requirements for medical necessity (i.e. missing treatment plan, including level of care (duration and frequency of visits), specific treatment goals, and objective measures to evaluate treatment effectiveness;
- 13.89% were denied as one or more of the Medicare requirements were missing from the submitted documentation and did not support the level of service billed.
In response to the CERT and review results, WPS performed further data analysis for chiropractic services for dates of service 6/1/2009 through 5/31/2010 to aid educational efforts. In J5 for this timeframe, there were 7,310 beneficiaries (274,519 claims) with 35 or more services billed per beneficiary. A high frequency of services per patient may indicate that some services are not for active corrective treatment (i.e. maintenance therapy) for which the AT modifier should not be applied. Due to this analysis and the results of these reviews, another concern is the appropriate use of the AT modifier. The CBR Report will contain data on the frequency of services per patient in comparison to peer norm.
Medical Review is utilizing a direct widespread educational approach to those Part B providers who bill a high volume of services per patient. Individual Comparative Billing Report (CBR) educational letters will be sent to those providers who bill only one of these Current Procedural Terminology (CPT) Codes 98940, 98941, or 98942 with the AT modifier 90% or more of the time and have greater than 1000 allowed services.
These providers will receive an educational letter along with a Comparative Billing Report comparing the individual provider to his/her peers in the J5 Jurisdiction. In addition, each provider will receive a Comprehensive Error Rate Testing (CERT) Program and Chiropractic Services Resources attachment to utilize.
Our philosophy at WPS Medicare is that providers and suppliers want to bill Medicare correctly and will do so if given the proper education and opportunity. To review the current educational material available on the WPS Medicare website please visit our Chiropractic services page available under the Resources tab, Provider Specialties/Services.
ALERT:
Effective November 1, 2011, there will be a new mandatory ABN form.
Access the new ABN here: http://www.acatoday.org/pdf/abn_2011.doc
Several doctors have asked what is an ABN Form.
An ABN (Advance Beneficiary Notice) is a standard Medicare form that is to be used to let a patient know what may not be covered. In order to fill them out properly, it is best that you go to Medicare's website and print out the instructions. Here is the link to that information: http://www.acatoday.org/pdf/abn_2011.doc
Non-covered services can be listed on the ABN form but it is not mandatory. Covered services are manipulations only. Maintenance manipulations are considered a covered service that is not medically necessary, and the correct way to put it on your claim form is to not put an AT modifier behind your manipulation code. You are required to have the patient sign an ABN form each visit that you are doing a manipulation that is maintenance care.
One of the questions I received was that the patient needs the care to prevent deterioration of their condition. If you treat them, and it is maintenance care, you must have an ABN signed and filled out properly; and you are required to bill it and not use the AT modifier for it. It is covered but not medically necessary. (NOT my verbiage)
This email is for Nebraska doctors on my list. If you are getting this email and you are in one of the other J5 MAC States (WPS Medicare) this information pertains to you also, however you should be getting a state specific email from your association and/or your CCAC Representative.
Attached are four documents/forms that we have worked on to help with the self audits, as well as other types of audits/reviews you receive from any of the Medicare contractors. I want to thank Denise Hoffman and Vicki Stoffer for helping draft these documents. These forms were produced by us and do not reflect endorsement of any contractor or CMS itself.
I also highly recommend you go to these Internet links (below), download and print them. Use them for auditing your initial visit and subsequent visit documentation and for further reference. (members may read the entire letter by clicking here)
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
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: info@drfreihaut.com
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.
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 also file complaints using this form:
http://insurance.mo.gov/consumer/complaints/
Insurance Committee Report
by Margaret Freihaut, DC
Chairperson
The report of the Office of the Inspector General (OIG), the study of whether chiropractic benefits were paid appropriately for claims paid in 2006, was released in May, 2009. The objective of the study was to determine the extent to which: 1) chiropractic claims were appropriate, in 2006, for beneficiaries receiving more than 12 services from the same chiropractor; 2) controls ensured that chiropractic claims were not for maintenance therapy; 3) claims data could be used to identify maintenance therapy; and, 4) chiropractic claims were documented as required.
The review was based on 200 claims where the AT modifier was used with more than 12 visits from the same chiropractor. For each treatment episode, the medical records were reviewed to identify the initial visit and subsequent visits to determine whether each sampled claim was active/corrective treatment or maintenance therapy; the extent to which chiropractors supported their use of the AT modifier with proper documentation indicating active/corrective treatment; whether claims were coded properly; and whether documentation met the Manual requirements.
The findings were: 1) Medicare inappropriately paid $178 million for chiropractic claims in 2006, representing 47% of claims meeting the study criteria. The breakdown was $157 million were maintenance visits, $11 million were miscoded, $46 million were undocumented, and $36 million were for multiple errors; 2) Efforts to stop payments for maintenance therapy have been largely ineffective; 3) Claims data lacked initial visit dates for treatment episodes, hindering the identification of maintenance therapy; and 4) Chiropractors often do not comply with the Manual documentation requirements. The medical reviewers indicated that treatment plans are an important element in determining active/corrective care in achieving specified goals. Of the 76% of records that reviewers indicated contained some form of treatment plan; 43% lacked treatment goals, 17% lacked objective measures, and 15% lacked the recommended level of care.
The Recommendations made by the OIG to CMS due to these “high error rates and poor documentation” were 1) Implement and enforce policies to prevent future payments for maintenance therapy 2) Review treatment episodes rather than individual chiropractic claims to strengthen the ability of the CERT to detect errors in chiropractic claims 3) Ensure that chiropractic claims are not paid unless documentation requirements are met and 4) Take appropriate action regarding the undocumented medically unnecessary, and miscoded claims indentified in the sample.
The above comments are taken from the Department of Health and Human Services Office of the Inspector General titled, “Inappropriate Medicare Payments for Chiropractic Services,” dated May, 2009. For the full text and more detailed explanations, you can get the actual document and review it.
This report reiterates how imperative it is for our profession to continue to work aggressively to improve our documentation. The 2009 work plan for the Department of Human Services Office, Office of Inspector General, includes chiropractic again. Please let the MSCA know if you get an OIG record request.
National Health Care
Have you signed up for the ACA’s ChiroVoice or the ICA’s Adjust a Vote? It is critical that you sign up yourself, your family and friends, and your patients. This is a website where you and your patients can get in contact with their legislators to help us have a strong voice and to help us make sure chiropractic is included in any national healthcare reform. Missouri ranks 19th with its number of individuals signed up on the ACA’s website with a measly 337. DOCTORS, if you don’t stand up for your own profession, how can you expect your patients to? Sign up today. We need to be ready so the legislators know we care whether we are included. I personally am very concerned about what kind of legislation may be put up for healthcare; but I know that, whatever it is, chiropractic patients need to have access to chiropractic.
Legal Action Fund
Do you know how hard the MSCA’s Legal Action Fund fights for you and your patients rights? Thanks to the Legal Action Fund, cases have been funded that have infringed on your rights to tell your patients what services you provide, like in the White vs. the Missouri Board of Healing Arts, cases where your patients have been illegally charged with high co-pays by several carriers in HMO’s. Did you know that several of these cases have been won, patients will be refunded, and the co-pays will no longer be more than 50% of the allowed amounts? Have you signed up yet? Why not? Do you think that someone else will take care of it for you? Take a minute today and send a one-time donation; or even better, a monthly contribution for the ongoing efforts that the Legal Action Fund is doing for you and your patients.
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