Answers to Common Chiropractic Medicare Problems

In my last article on The Perennial Problem of Medicare for Chiropractors, I offered to respond to some common questions and dilemmas that you have been experiencing in regards to Medicare and your chiropractic practice.  Since the blog was posted last week, we received a total of 326 responses with questions, comments, angry remarks about CMS and a few demonstrations of our collective chiropractic misunderstandings about all things Medicare.

In other words, the rumors are still out there, docs are still frustrated and problems still abound.  To be fair, I did receive ONE response from a DC who was a bit perplexed about all the fanfare and indicated that Medicare was the easiest payer to deal with.  Certainly, his response was the exception, not the norm. The one caution I would raise for docs who similarly feel that they are sailing along without any trouble: the RAC audits have started and they may change your opinion of the matter.

Now, let’s get to the questions!  Obviously, I cannot address all 326 responses, so I have summarized the concerns into a few basic categories as follows:

Payment Denials or Downcoding. Several readers were upset that Medicare had denied or downcoded the level of service and paid them less (or not at all) as a result.  More were confused about what this means.   Since your adjustments are the only service Medicare pays chiropractors for, the “level” of service refers to the number of areas that you adjust and bill for – i.e.  98940, 98941 or 98942.  When I perform Documentation Reviews for clients, the most common mistake I see here is that your objective findings don’t match the level of service billed.  In other words, you billed a 98941 (3-4 region adjustment) but only had objective findings for perhaps 1 or 2 areas (or less).  Therefore, Medicare concludes that either you didn’t meet medical necessity for the service you performed at all or that you only met medical necessity for a service that was lower (fewer areas) than the one you billed.  The result: your claim will be downcoded (i.e.  a 98941 will be paid at 98940 rates) or denied ( you didn’t meet medical necessity at all).

Fixing Problem Claims. This question of what to do with incorrect, incomplete, or problematic claims came in a variety of formats.  Per Medicare Transmittal 1588,  you can submit a corrected claim if your original claim was filed in a timely fashion and was incomplete.  By incomplete, Medicare means items are missing such as NPI #, patient demographic info or other such requirements on your claim form.  Incomplete does not mean that you get to re-submit your corrected claim because your original clinical documentation was substandard or missing items you should have included in the first place.

Error Rate and the Aftermath. Error rates probably mean bad news for most DC’s!  Error rates are the % of claims submitted in error to Medicare that are determined to be such after a review. Error rates can result in overpayment demands (Medicare paid you, but since 20% of your claims were in error, they want a refund) or can lead to future audits (your error rate is too high, therefore Medicare will audit you again in the future to monitor your progress) or can even cause “Pre-Payment Reviews”  (Medicare determines that your error rate is repeatedly too high and they will have to review your documentation prior to approving any future payments).  As I said at the start, none of this is good news, although if you are receiving notices of PrePayment reviews, you definitely need help in the area of proper billing, coding and documentation.

Avoiding Medicare Patients. Some of you indicated that the only sure-fire way to avert Medicare disaster was to avoid treating Medicare patients.  Certainly, you have the right to refuse to treat Medicare patients so long as you do so within the confines of your state laws.  Whether this is a good tactical move may be questionable, as the Baby Boomers represent the single largest segment of the population who will be driving lots of healthcare dollars in the name of Medicare.  To exclude them may represent a significant portion of your practice base.  Also, be careful when you state that you do not treat any Medicare patients.  By the questions some of you posed (whether hypothetical or not), you ARE treating Medicare patients but you are simply not billing Medicare for the service.  If you are not doing this correctly, you could be accidentally committing fraud by doing so.

Medicare, EMR and Stimulus Funds. Several questions came in regarding integration of EMR and Medicare.  According to the program, physicians (including chiropractors) will be eligible to receive stimulus funding as soon as 2011 for EMR that meets certain “meaningful use” criteria.  At this point, the specific details of these requirements are still to be determined.  While I am a big proponent of moving to EMR, in this respect, I agree with the ACA’s advice on the matter: “do so with the fundamental focus of improving patient care.”  In other words, get the EMR because you want it to help your documentation, your clinical practices and business management – not because you may get some money from the government.

CERT Request and Audits. Apparently, there are many of you who wonder if CERT requests are an audit.  CERT stands for Comprehensive Error Rate Testing and it’s likely many of you have received such a notice from Medicare.  It is their way of randomly testing the accuracy of payments made.  So the key word is random and is in no way an indication that you are doing things wrong (or right for that matter).  Comply with the request and do not ignore it.  For more detailed information on the Audit process (for both Medicare and other third party payers), types of audits and what to do I suggest you get a copy of How to Prepare Your Chiropractic Practice for Recovery Audits so you can understand what auditors are looking for and how to respond.

ABN Mysteries. ABN questions dominated my inbox in varying forms and it’s obvious there’s still a lot of confusion over ABN’s.  First, by definition the ABN is an advanced notice (meaning, you have to give it to the patient beforehand not to cover your tracks afterward) that Medicare may not pay for the service you are about to render.  Secondly, to simply have your patients sign an ABN each and every visit is incorrect.  It presupposes that none of your chiropractic adjustments are necessary. This is not something you want to communicate to Medicare or your patient!  Finally, for more detailed discussion of ABNs, let me refer you back to an older post entitled: ABN Abuse: A Common Chiropractic Practice.

FREE or Discounted Medicare Services. The “Can I include Medicare patients in my Free or Discounted…” question was posed in several ways, but the same theme is underlying.  What can I give away or discount to my Medicare patients? Here is your answer. According to OIG interpretation of Section 1128a(5) of the Social Security Act, exam specials, coupons, or similar discounts should not exceed $10 individually or $50 annually per patient.  So, your FREE exam or adjustment may be problematic in that it either exceeds the $10 value or that you don’t charge enough for your services.  One way, you’re in trouble with Medicare; the other, your business is not likely to generate a profit if you are charging less than $10 for exams, x-rays, adjustments, etc.