Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. We suggest you watch the video while reading the transcript.
Hi, everyone. My name is Michael Miscoe with Miscoe Health Law with this week’s presentation on behalf of ChiroSecure’s Grow. Growth without risk podcast series and today we’re going to talk about medicare billing. I know I’ve talked about this in the past but a couple cases have come in recently and As well as compliance calls that tell me that we need to do this topic again, and the subject is basically Physicians Misconception about their obligations to submit claims on behalf of Medicare beneficiaries.
Click here for the best Chiropractic Malpractice Insurance
And as we work through this essentially, we’re going to talk about what your statutory obligation is, more importantly, what it applies to and what it does not. And then we’ll also talk about. The concept of medical necessity as it is defined and applied under the Medicare program by the various integrity contractors like your supplemental medical review contractors, your SRCs and the uix, the Unified Program, integrity Contractors, not to mention the OIGs cert or comprehensive error rate testing processes.
How they look at medical necessity is very different than how you do. Let’s start with the statute. Now, I know that many of you have been to Medicare lectures maybe on the Medicare calls, and may, and have walked away with this perception that if you see a Medicare patient, and I’ll even be more precise, if you treat a Medicare patient, you have an obligation to submit a claim to Medicare on behalf of the Medicare beneficiary.
Get a Quick Quote and See What You Can Save
And that is not Entirely true. Okay. For a couple of reasons under the Medicare statute. 42 U. S. C. section 1395 W hyphen 4 subsection G subsection for subsection little a. At that is where the statutory obligation to bill Medicare comes from the limiting fee provisions are also in that subsection.
G. and what you find when you read that statutory section is that whether you’re participating or not. Okay, participation status has nothing to do with this billing obligation unless you are an opt out physician, which is chiropractors. You cannot be only medical physicians. M. D. S. and D. O. S. can opt out of the program.
And what that means is when they opt out, they are permitted to provide covered services for cash and not submit complaints. Claims to Medicare. So for chiropractors, podiatrists ophthalmologists, PTs, any other type of physician or qualified healthcare provider, you can’t opt out and provide covered services, but you can functionally or practically opt out because of the limits of what your statutory obligation to bill are.
And in the statute, it says you are obligated to submit a claim for services Which may be paid under this part or which are payable under this part. And what they’re talking about is part B. So I don’t want you to confuse Medicare. Part C. That’s a whole different animal. That is your billing obligation in that context is contractual.
With the Medicare Advantage plan pair and you are likely to find, whether it’s the blues or Medicare Advantage plan or United Healthcare Advantage plan. When you look at your participating provider agreement, you are likely to find that you only have an obligation to bill for covered services now.
In the Medicare Part B context, services that are payable under this part means that the services are covered. Coverage analysis comes in two steps. First step is it a benefit? Meaning, is it something that Medicare will potentially pay for? And the second step is, if it’s a benefit, Is it medically necessary?
With respect to the medical necessity side of the analysis, that analysis does not arise for a service that is statutorily excluded from payment in the first place. And let me give you an example, as doctors of chiropractic you are classified as physicians. for purposes of the Medicare program.
But your status as physicians is limited to performance of manual manipulation of the spine. And we’re going to get very precise about those terms. It doesn’t say manual adjustment of the spine. It doesn’t, it says manual manipulation, and we’re going to get very pointy headed about what that. What the definition of manipulation is in a minute.
I don’t mean to ruffle anybody’s feathers, but I’m here to tell you what the rules are. Now, if you do an exam, x rays, electrical stimulation, mechanical traction, therapeutic exercises, whatever’s in your scope of practice that is fine. But those services, because they’re not manual manipulation of the spine are statutorily excluded from coverage.
You’re not considered a physician and therefore you’re not entitled to reimbursement when you perform services other than manual manipulation of the spine. With respect to our coverage analysis, those services are not a benefit. And therefore, they could be the most medically necessary services in the world, but they’re never going to be covered.
Okay. And that is significant when we start talking about ABNs, which we’ll get to in a minute. So we have to look very carefully at what is manipulation. Now, in some states, like where I’m at in Pennsylvania, there is a statutory, state statutory definition in the Chiropractic Practice Act that specifically defines manipulation.
In here, it is movement of the joint. Beyond the passive range of motion into the paraphysiologic range of motion without exceeding the boundaries of anatomic integrity for the purposes of reducing subluxation or causing cavitation. So we’re talking about predominantly HVLA type manipulative techniques.
Some of you are probably aware, or maybe you’re not aware where it comes from, but there is a provision in the Medicare Benefit Policy Manual, which is Internet Only Manual, Pub 100 2 Chapter 15, Section 240 1, clarifies the manual manipulation thing with respect to the use of instrumentation.
Medicare CMS in, in that provision indicates that manipulation performed with a manually controlled instrument is covered, if it’s medically necessary and so forth. They create this exception that if you use an instrument, To perform manipulation, that’s fine as long as the instruments manually controlled.
What they don’t say is that instrument adjusting is covered. Okay. Interestingly enough, Medicare equates the word adjustment with manipulation for their purposes, but in the industry, those 2 terms don’t always. Coincide. So under the definition that I gave you, which is similar to definitions in a number of states, because it used to be the National Institute of Health PubMed definition, that definition was recently revised, and essentially it boils down to manipulation occurs when you cause cavitation.
So whatever it is that you’re doing, if it causes a cavitation, it’s manipulation. Now, the reason that is significant is that for providers who do not. want to bill Medicare, the easiest way to not have to bill Medicare is don’t do anything that Medicare covers. So don’t do manual manipulation of the spine, or don’t do manipulation with a manually controlled instrument.
What if the technique that you perform merely mobilizes the joint within the active or passive range of motion and doesn’t cause cavitation? That makes it not a manipulation, therefore it’s not a benefit, and therefore you have no obligation to bill. Okay. Now, the reason why providers are turning in this direction is twofold, I think.
Profit and risk, and I think those two things are tied together. On the profit side of the equation for those that have ever been through a Medicare post payment audit, you come to realize very quickly that if you haven’t filled in all the blanks in for the initial visit and those are defined in the benefit policy manual chapter 15 again, public 100 to chapter 15, section 240.
1. 2. 2. a. And there’s a whole laundry list of things that have to be there and I have personally seen Medicare administrative law judges deny care is medically unnecessary because 1 of the history present illness elements was not addressed. Those elements are location, quality, severity, duration, timing, context, associated signs, symptoms, modifying factors.
The provider didn’t address one of them, likely because it was irrelevant. But because that was missing, the judge determined that the documentation content requirements were not satisfied and that arbitrarily or may lead to a per se conclusion that the care wasn’t medically necessary, which suggests that in Medicare, filling in all the blanks is a prerequisite to a determination of medical necessity, which I can argue that point all day long.
Okay. Filling in the blanks does not make care medically necessary. I would argue that circumstances and maybe filling in all the blanks may justify necessity, but fundamentally, Medicare and their auditors, and even in the commercial space, when you don’t fill in all the blanks that they say you’re supposed to fill, they’re going to take the money back.
That’s a practical reality. I’ve been involved in probably somewhere close to 500 Medicare appeals, and That is a consistent scenario. Every once in a blue moon, you run across a judge, who gets it that the paper doesn’t make the care medically necessary. The circumstances, the expectation.
In fact, Medicare 240. 1. 3 actually has a definition of what medical necessity means for manipulation, manipulative treatment and it’s, Crazy that they come to a conclusion that care is not medically necessary and never evaluate those elements, okay? So to do all the work in the documentation that Medicare requires, of course, you, you do an evaluation management service and you get paid for that by the patient.
Okay. But that code is going to be a 99203. It would only be higher if you were using time and that. Cost burden falls to the patient in many docs don’t like to burden Medicare patients with the cost of an initial examination and x rays, or they want to reduce or discount them because Medicare doesn’t cover it.
And we could talk about the kickback problems that you create when you arbitrarily deflate the cost of that. Which is a prerequisite to get into a medically necessary course of care. But even if you’re collecting the Medicare rate for your exam and your x rays, it’s going to come out to be like 200 bucks.
And you’re going to spend an hour of your time or more writing a treatment plan that you pray that your patient is going to actually follow. Okay? If even if they do, the Medicare average Patient visits per patient per year is like 5. 4. Okay. So if you’re getting beyond that doing routinely 12, 14, 16 visits per Medicare patient, you’re going to be an outlier and you’re going to get clubbed over the head sooner or later.
And if your documentation is perfect, you might survive, but do the math. Let’s say you did 10 visits at, let’s be crazy and say 40 a piece, that’s a 400 case that you are going to have an hour and a half setting up, enforcing patient compliance, doing progress management and the documentation burden is so severe, you can’t make money.
It is a a diminishing or it’s the work versus the reward just doesn’t make it worth it. The amount of money you could make doing cash services, even at 40, 50 bucks a visit far outpaces what you can earn doing all this documentation work that you have to do for Medicare.
And having, worked with a few doctors over the last 30 years, I’ve come to the conclusion Most of you did not go to doctor school to learn how to write narrative reports. You wanted to learn how to treat patients and that’s where your passion is. The more time you spend with your hands on patients than hands on your computer the better off you’re going to be and probably the happier you’re going to be.
All right, that’s the end of part one. Next time we’ll continue our discussion with the Medicare billing requirements.
Click here for the best Chiropractic Malpractice Insurance
Get a Quick Quote and See What You Can Save