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, this is Michael Miscoe with Miscoe Health Law, and today we’re gonna do part three of our three part series on debunking the Medicare billing myth. Now, underlying all that, they’re, they introduced the word significant patient has to have a significant health problem, significant functional deficit.
Click here for the best Chiropractic Malpractice Insurance
So you’re, the patient’s doing some aggressive feather dusting over the weekend, or they move the chair or they slept on the couch. That’s just not. Perceived as causing a significant health problem. And more often than not, your treatment plan, the patient’s gonna come one or two times and they’re gone.
And so you’re gonna try to spend 30, 90 minutes or 60 90 minutes of your time writing a treatment plan around something that you know is gonna be over in two visits. Even if you filled in all the blanks and it was two visits and the patient was gone, they would determine that the care was palliative and not cover it.
Get a Quick Quote and See What You Can Save
Usually the documentation doesn’t force them to make that judgment. ’cause they can point to holes in your documentation. But if they have to, for docs that are filling in all the blanks, that’s where they go. They’re looking for somebody that you know is not a frequent flyer in your practice. And when you evaluate your patients under these standards, you realize that probably 85% of your patients should be cash anyway.
Every once in a blue moon, somebody comes in and there’s a serious hurting can of corn and you set up a treatment plan and you don’t have to convince them. To stick to the plan, they’re doing it because they’re hurting that bad, and you’re in and out of it in maybe two to four weeks on average.
Hopefully less than that because otherwise you’ll be an outlier. But if your documentation’s good, you could justify it. The question is it worth it? And many providers are concluding that it is not. But if you want to do that’s fine. I could certainly show you how the the documentation works, how we, track objective, measurable progress throughout the course of care and we so that we can absolutely win that medical necessity fight.
But I will tell you, it is a lot of work. There’s no EMR program that does it. And that’s unfortunate. So it’s gonna require a lot of manual tracking. An effort on your part to move your documentation in that direction. And for those of you that think you have bulletproof documentation, but you’ve never been through an audit, trust me, you don’t.
There’s always something there for them to pick on. Especially if you’re using EMR programs that are commonly sold to the chiropractic profession these days. And it’s not a hit on the EMR programs, it’s just they do what. Doctors have been traditionally taught to do in documentation.
Unfortunately, they haven’t really paid attention to what the payers are looking for. When you consider my post-payment audit experience for the last 20 some years, both as an expert and as a lawyer you see some common themes coming up and unfortunately, the systems that docs are using are in part, docs are looking for an efficient way to document care.
Unfortunately, that’s gonna lead you into a brick wall from a medical necessity audit perspective, and sometimes. The tools don’t provide the level of detail or the content that payers are actually looking for, because in many case, what they’re looking for isn’t established in their policy, and the only way you figure it out is looking at their objections and starting to draw common themes.
So that being said, let’s say you do. Perform manual manipulation of the spine or manipulation with a manually controlled instrument, and you don’t wanna bill Medicare, then your only out is the A BN, the advanced beneficiary notice form. Now an A BN according to Medicare is used only when you have a service that is a benefit.
But for this patient and this date of service is not covered for reasons of medical necessity. So an A BN would only be done by a chiropractor for manual manipulation. The spine, nothing else goes on the A BN. Okay. Medicare does permit course of care, ABNs, so some providers think, oh, I just do an A BN at the beginning of the year and I’m good.
No, you’re not okay. To provide effective notice because medical necessity is truly a service specific determination. You need to do an a, b, N every visit. Now I’ve taken an a BN form and put 24 spots on the back, not because Medicare will necessarily agree with that, but just to demonstrate that we’re trying to put the patient on notice that their stuff isn’t covered and giving the patient the election.
In theory as to whether the service should be billed or not. And I’ll get to that in a second. One thing you have to understand about ABNs, if you do ABNs, let’s say option two, and the services aren’t billed and the Medicare patient calls Medicare to inquire why their claims aren’t being paid, I don’t care how perfect your A BN is, Medicare is going to determine that your A BN did not provide sufficient actual notice.
Of the patient’s obligation to pay and they’ll toss it and they’ll make you refund the money. And it is a real big kick in the teeth. And when I see this happening, it tells me that the onboarding process of your Medicare patient did not get into as much detail as it should. Sure. There are always these people that are gonna purposely not understand.
I. Just understand when you do manipulative care, that is a possibility. It doesn’t happen very often. I think it’s maybe happened five or six times since I’ve been doing the Medicare cash consults over the last 12 or 13 years. But when it happens, docs get really upset and reasonably now. The A BN has three options. Option one, I understand the service isn’t medically necessary but I want you to bill Medicare so that I can have appeal rights, okay? A complete waste of time and overhead expense. Why? Because when you bill A CMT code, 9, 8, 9, 4, 0, 1 or two. Without the AT modifier, meaning that it’s not medically necessary and with the GA modifier, so that when the carrier processes it, they deny it on a PR code, a PR 50 instead of a co.
Okay. PR means you can build a patient co means you can’t. Okay. When that happens. Okay. That it’s not gonna get paid for. So you’re going through this administrative drill to prepare a claim, submit it, pay the clearing house, then deal with the EOB, then send a statement to the patient. And then the patient apparently wants to submit an appeal and they do have administrative appeal rights.
Okay? But they’re not gonna work. Okay. Because the moment the provider documents the service as being something that’s either palliative, preventive, supportive, maintenance, wellness, or preventive, there’s no judge on the planet that’s gonna look at your documentation and go, oh, that really should have been medically necessary.
Okay? And Medicare should have paid it. It’s just not gonna happen. In the infiniteness of ever, never. It’s never gonna happen. All right, so the only real option to make this care reasonably affordable or cost effective to provide is option two. Now, Medicare will tell you that you cannot influence the patient’s selection of the option.
You can’t pick it for him. You can’t tell them to pick option two, but what you can do, which I verified on a call with Medicare back when they used to let me participate in these things is that you don’t have to provide the service if they pick option one. Okay. ’cause it’s just not. Gonna be financially in your best interest to do that.
It’s a lot of work for nothing. You’re not gonna get payment, and then now you’re gonna have to bill a patient and they’re upset and they don’t wanna pay you. It, it eliminates any potential profitability in providing the service a BN option two. You can tell a patient, look, you’re free to pick whatever option you want, but if you pick anything other than option two, this visit’s not happening.
Okay. And you gotta be serious about it because I will tell you, if you look at your practice over the years, especially been in practice for a while, think about every very annoying or very pain in the butt or abusive patient that you’ve ever had, and it’s gonna be somebody that didn’t wanna play by your rules.
The rules of your practice, they’re somebody that you bent your rules for to try to accommodate. And trust me, at the end of the day, you cannot accommodate those kind of people enough. You could offer to pay them to come to your office and they still wouldn’t be happy. They’d want more. Okay? Set the rules.
If you wanna deal with Medicare and you wanna go down this path it’s option two or take the choocho train. Now some practices like to straddle the fences, I like to call it, meaning they will initiate care with a Medicare beneficiary. They will go four to six visits and then they’ll convert ’em to cash.
Fine. Okay? However, I. You have a six year lookback period with respect to those services where you can either get audited, Medicare can reopen going back maximally five years. And if you get selected for audit and it turns out bad, because the documentation of those initial that initial course of care doesn’t meet.
Medicare requirements either for content or establishing a significant health problem, significant functional deficit, and evidence that the care resulted in significant improvement. If that doesn’t happen. And if you’re using standard EMR systems, it probably won’t. Then. Not only are you gonna have to pay that money back, but it may create voluntary disclosure and refund risk for you.
So I don’t recommend it. Now, understand, I represent physicians and post-payment disputes with Medicare and commercial payers. It’s all I do. I have zero motivation to tell you to go cash, okay? If I were in your shoes, that is exactly what I’d be doing. I have many clients that have made the move to cash where they are making 65, $70 out of a Medicare patient visit.
And that’s straight up manip. That’s just what they charge, and you can either pay it or take the train. And surprisingly they have very busy practices I think chiropractic. The, lemme see. I got involved in Medicare billing in my dad’s practice in 19 78, 79. Literally piping back then they were called HIA 1500 forms.
Where. Chiropractors were just getting involved in insurance billing, and now it seems to have gone full circle where the more successful practices are moving away from insurance and all of the post-payment risk. And an overhead expense that goes with it. It’s just a crushing burden of requirements and actually had a discussion with a legal colleague looking forward in, in terms of what’s gonna happen with the reimbursement system, both Medicare, medicaid commercial payers, and, ultimately it’s gonna have to move to something different. And only because physicians cannot keep up with all of the requirements that have been landed on them for no extra money.
Okay, you’re gonna do all this work for a two, $300 case. Just, you can’t make money that way. So hopefully what you decide to do is your choice but hopefully you understand that there is an option. To treat Medicare patients without having an obligation to bill Medicare on their behalf. And if you’d like to know more about it, feel free to reach out.
But it is something that has restored and I’ll tell you a quick story before we finish up. Had a client recently that when her patients turned 65, she would dismiss ’em as soon as they went on Medicare Part B, sorry. You can’t be in the practice anymore ’cause I don’t wanna bill Medicare.
Literally turning people away, sending them down the road and was very surprised and overjoyed, in fact, to find out that there was an option where she could retain patients that had been with her for years. And continue to provide a. Care that the patient wanted, care that the patient trusted.
This misperception that if you see Medicare patients, you have to submit claims on their behalf. It’s just not true if you walk away from anything, hopefully you get that much of it. And if you want to learn more, I encourage you to go read the statute and the publication requirements that I pointed out to affirm that for yourself.
I think we went a little long and I hope that wasn’t too boring for you. But I appreciate your attention and time and we’ll see you next time.
Click here for the best Chiropractic Malpractice Insurance
Get a Quick Quote and See What You Can Save