Know the rules and regulations to navigate Medicare reimbursement
THE OXFORD DICTIONARY DEFINES confusion as “the state of being bewildered or unclear in one’s mind about something.” Chiropractic coverage under Medicare has expanded. Many Medicare Advantage Plans (Part C) have increased reimbursement for services performed by a chiropractor. The confusion about coverage, coding, billing and patient liability has also increased with expanded benefits. Knowing the rules and regulations will help the chiropractor navigate the muddy waters of Medicare reimbursement.
Meeting the standard of care
Chiropractors are held to a standard of care, as are all physicians. We are tasked with providing care to a segment of the population with chronic deteriorating conditions. Degenerative joint disease, disc degeneration and loss of balance causing falls are just a few of the issues we as practitioners see in our elderly patients daily.
Falls are the leading cause of injury and death among adults aged 65 and over. Falls in the elderly lead to 36,000 deaths per year, three million emergency department visits, and one million hospital stays.1 Chiropractors are poised to help patients with chronic subluxations by assessing their condition and offering spinal manipulation, extraspinal manipulation, three-arch custom flexible orthotics to balance and stabilize the body, and rehabilitation services to treat these conditions correctly. However, we know not all services the doctor recommends may be covered by insurance.
While a chiropractor cannot opt out of Medicare (MedLearn Matters, SE0479), we face the dilemma of abiding by regularly changing regulations. According to recently released data from the Centers for Medicare and Medicaid Services (CMS), Medicare Advantage is a private plan providing Medicare coverage for just over half of eligible beneficiaries. In January 2023, 30.19 million of the 59.82 million people with Medicare Part A and Part B were enrolled in a Medicare Advantage Part C private plan.2
Competition in Medicare Advantage Plan has expanded chiropractic benefits
With the increased availability of Medicare Advantage plans, the competition for patient enrollment has led to the expansion of benefits each company offers, thus trying to lure patients to their plans. Even services, such as maintenance spinal manipulation, which have never been covered in the past, are now being covered as “routine benefits.”
Medicare Part B recently updated its Advance Beneficiary Notice of Non-Coverage (ABN) form, the CMS R-131, with an expiration date of Jan. 31, 2026, took effect on July 1, 2023. While it is the physician’s responsibility to inform the patient of the likelihood the patient will have to pay out-of-pocket expenses, the ABN form is only mandatory for spinal manipulation. The ABN form is considered voluntary for services other than spinal manipulation.
CMS expressly prohibits using the ABN form in the Medicare Advantage Part C program.3 The regulation causes the chiropractor to consider using other documents, such as the Good Faith Estimate (GFE) form in the No Surprises Act (NSA). The procedure seems simple until you consider that coverage of services under Part C varies widely. When one calls the insurance administrator for the Part C insurance plan, they inform you that as long as you are a provider for Medicare, you are in their program. Plans must cover all medically necessary services and supplies that original Medicare covers.4 The representative will quote you the benefits with the disclaimer that there is no guarantee of benefits.
Specific plans within the Part C Medicare Advantage plans may cover maintenance care. Plans such as AARP® Medicare Advantage, United Healthcare® Dual Complete and United Healthcare® Group Medicare Advantage may cover maintenance spinal manipulation. There may be additional United Healthcare plans as well with this benefit. Since Medicare Advantage plans are private contracts within the Medicare system, the benefits must be verified before services are rendered.
When the provider verifies benefits for any United Healthcare Medicare member, they must ask the representative if the member has the “routine benefit,” and if so, how many routine visits are covered. If the member has these benefits, they are there to use when the care is not deemed active treatment by the Medicare definition, the treatment is for pain or neuromusculoskeletal disorders, and the treatment is used at the member’s discretion.5
Essentially, the benefit of these plans allows for a certain number of visits for non-active treatment. The altered coverage would be a variation where the United Healthcare member’s care no longer meets Medicare’s “active treatment” definition.
The typical scenario may be when a United Healthcare member initially comes in for active chiropractic treatments. The provider would append the AT modifier to the CPT codes 98940-98942 and then bill that care to United Healthcare. The provider would then discharge the patient from active treatment once they are at maximum improvement with their care. If the patient returns later to the office for care that no longer meets the Medicare definition of active treatment, the provider would bill that non-active treatment as the “routine benefit” to Optum. The doctor must choose on each visit if the care is active or routine, document it as such and bill all services for that visit to the correct payer. Since Part C does not use the ABN form, you would bill active care as 98940-98942 with an AT modifier and maintenance care (routine benefit) as 98940-98942 with no modifier.
The procedures for each carrier vary. Companies administering Medicare Advantage plans, such as Blue Cross Medicare Advantage, have established their own forms to limit the liability for the patient and the physician. Still other plans now require a preservice organization determination (OD) notice for services in Medicare. Now you can see why patients and providers are confused. Health insurance companies employ prior authorizations to obtain insurer approval before providing specific treatments. This process complicates the delivery of care and wastes administrative time.
Documentation is the lens
As in most cases, documentation is the lens that brings into focus all details. As long as the chiropractor does their due diligence to inform the patient of their benefits according to their carrier and correctly documents there is no guarantee of coverage until the claim is sent in, the patient may be liable for payment. The process preserves the decision for care as a doctor-patient decision.
Therefore, with the recent developments in the Medicare Advantage program, benefits should be verified before services are rendered. Just as the insurance company gives no guarantee of coverage, the chiropractor should not imply a guarantee of coverage either. Instead, inform the patient, “according to their insurance carrier,” this is the coverage they indicate for your plan. There is no guarantee of coverage until we send in the claim. The process should then be documented with the ABN form and other forms in Part B Medicare and the GFE or other forms mandated by the carriers in Part C Medicare.
For example, spinal manipulation in Part B would be filed with the AT modifier for active care. If the patient requests filing a claim for maintenance care, it would be filed with the GA modifier as long as a signed ABN form was obtained. In Part C Medicare, the spinal manipulation would be filed with the AT modifier for covered services and with no modifier for maintenance care. If the patient has coverage for maintenance spinal manipulation, no modifier will route coverage under the routine benefits provision of coverage. If they do not have coverage, filing the spinal manipulation with no modifier in Medicare Advantage will yield a denial. In this case, the GFE or other approved forms will document the patient was informed they would be responsible for payment for the service.
Thoroughly assessing each patient and recommending the necessary care, without regard to insurance coverage, will improve patient care by establishing high standards. However, proper coding is essential for Medicare claims because codes are generally used to determine coverage and payment amounts.
In a world where Part C Medicare seems to stand for confusion, knowledge of proper billing and coding practices and adequate documentation of communications with the patient will always result in improved informed decisions between the doctor and the patient.
MARIO FUCINARI, DC, CPCO, CPPM, CIC, is a Certified Professional Compliance Officer, Certified Physician Practice Manager, Certified Insurance Consultant and a Medicare Carrier Advisory Committee member. As a Foot Levelers Speakers Bureau member, he travels throughout the year to speak to audiences nationwide, sharing his chiropractic expertise and insights about documentation, compliance and optimal patient care using custom three-arch orthotics. For further information, email him at Doc@Askmario.com or check his website at Askmario.com.
REFERENCES
- Facts about falls. Centers for Disease Control (CDC) webite. https://www.cdc.gov/falls/facts.html. Accessed July 29, 2023.
- KFF analysis of CMS Medicare Advantage Enrollment Files, 2007-2023; Medicare Chronic Conditions (CCW) Data Warehouse from five percent of beneficiaries, 2007-2017; CCW data from 20 percent of beneficiaries, 2018-2020; and Medicare Enrollment Dashboard 2021-2023.
- Medicare Advance Written Notices of Non-coverage, MLM Booklet, MedLearn Matters, MLN006266, June 2022, pg.11.
- Understanding Medicare Advantage Plans, Centers for Medicare and Medicaid Services. pg. 7. https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf. Medicare website. Accessed July 29, 2023.
- Determine the Right Benefit for Chiropractic Claims, Optum Policy 0069. Optum website. https://www.myoptumhealthphysicalhealth.com/public/document/?documentType=ReimbursementPolicies&documentName=0069_Supplemental_RoutineChiropracticServices.pdf. Accessed July 29, 2023.