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greetings. It’s Sam Collins, the coding and billing expert for Chiropractic, ChiroSecure, and you, and of course from H .J. Ross. I’ve been getting a lot of contact over the last week or two on the VA, and I’m sure some of you are getting recoupment letters saying, Hey, we overpaid you. We want money back. So the VA Community Care, while it’s good, is doing some things here for payments that may be recouping.
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We want to make sure, are you doing the right things to make sure when you do or don’t have to pay this back. So let’s talk about it. Let’s go to the slides. Let’s talk about what’s going on with VA Community Care. Now, if you’re familiar, VA Community Care, for those of you who have joined, if you’re on the East Coast, it’s through OptumHealth.
If you’re on the west coast, which means Texas and west of Texas, it’s through TriWest. And it’s a service that you’re allowed to provide veterans care in your office and pay through what’s called community care. It pays quite well. Pays for an adjustment, a bunch of therapies, and other things along with it.
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The only thing is it does have to be authorized. Now, within this authorization, they give you lots of services you can do. Chiropractic manipulation, exams, x -rays, and a myriad of therapies. Well, what’s going on though is that we’re now getting letters from some providers that are coming back and saying that they want some money back.
So, let’s get to the slides, let’s talk about it and see what’s going on with this recoupment. So, here’s a letter, this is a small version, I just want you to see, it’s coming from TriWest, but let’s blow it up here, and this is what we’re getting. It says, the purpose of this letter is to inform you that the pricing information, allowable reimbursements on a claim previously paid to you has been adjusted.
Thank you for watching. And given the correct payment was lower, we want the money back. And in this particular office, it’s being asked for $388 .58. Part of you is thinking, well, wait a minute, how did you overpay me? What do you mean they paid more? Because of course, these payments are pretty standard.
They pay according to Medicare rates. So that being said, how was it overpaid? Well, let’s get into that a little bit. How was this overpaid? What did they pay more of? Well, since the VA pays at Medicare rates, if they paid at Medicare rates, How could that be overpaid? You know, Medicare for an adjustment 31 to 40 for 4041.
You’re looking at therapies if they’re hands -on maybe in the low 30 range, modalities maybe in the teens. So needless to say, what was overpaid? Well, they’re paid or should have been paid on what’s called the multi -procedure payment reduction. M. P. P. R. This is something that I’m sure some of you have witnessed with certain carriers, OptumHealth, a lot of federal claims, particularly Medicare, though we don’t bill Medicare for therapy, so we’re not as familiar.
But what this is, it’s a procedure where or a protocol where they pay the first fee or the highest value fee, and then they And then each subsequent service is paid at what’s reduced. That’s called the press practice expense reduction, which is says it’s at 50%. But let me qualify. It’s 50 percent of the practice expense.
Realize that each code has values based upon several factors. The work value. Practice value, which includes things like your malpractice and so forth, but also practice expense, which means like setting up the room. So by example, if you’re doing a therapy where you have to set up an exercise room, there’s an expense part of that.
Well, if you’re setting it up for the first 15 minutes. You don’t have to reset it up for the second 15 minutes. So the idea for them is to take that portion out and that roughly is that 50 percent ratio, which it’s not 50 percent of the code, but about 15%. So we’ll get into that. And that’s something they should have been doing.
Now, my frustration is. Now that they’ve done that and they want to come back much later, are there ways to push back on that? Absolutely. Now, what we should be seeing now is them paying it correctly. What you, what you’ll notice that codes that you were paid, you know, like a secondary service that you were paid $31 will probably be about $27 or $28.
It’s usually about $4 to $5 per code. So here’s how it works. The primary procedure is reimbursed without reduction. And the practice expense portions of all secondary and subsequent procedures from the same year From the list, and I’m going to show you the list that they have on the same day to reduce 50%.
I want to highlight that 50 percent is not a 50 percent of the total fee, but 50 percent of the practice practice expense, which is a portion, and it’s roughly going to be about 15 to 20%. And it basically applies to physical medicine codes. Notice exam codes. Chiropractic codes don’t apply. Those will be paid in full, but it’s the therapy code.
So things from 97012 mechanical traction all the way through, you know, functional performance testing. For the most part for chiropractic, it’s generally going to equal your modalities and your typical procedures like exercise, massage, therapeutic activities, and so forth. So here is the list of codes that is allowed under what’s called the VA state code.
And you’ll notice all the codes. I mean, they have dry needling. They have acupuncture. You’ll even notice here. They’ve got all these therapies listed. So notice 970121897022. In other words, all of the therapy codes will have that practice expense reduction. And so that’s where you’re seeing that. So now it becomes, well, you know, it’s a little bit more complicated.
So, can they really force me to pay it back? Can I dispute this? Well, one of the things I have issue with is just straight statute of limitations. There is a 365 -date statute of limitations under the federal government. Therefore, I would argue, number one, if the request for this refund is more than 365 days from the date they paid it.
Now, be careful. The date you may have billed it may be within that time. If the date they paid it is after 365 days. That could be so that 365 days is going to be from date of payment. That’s going to be number one, because I’ve seen a lot of offices with disputes that are going back to 2023. And I’m like, whoa, whoa, whoa, that’s a little too long.
The other is just straight case law. For those of you that are network members, you’re familiar with that letter. If you’re not, please contact me again. This is for my network members, and we have a dispute letter for you. That kind of deals with both of these aspects, not only the 365 date statute of limitations, but the case law and how the case law works is this.
When an insurance pays something improperly, but not something you’ve done improperly, they have to stand by it. Now, certainly they don’t have to pay claims after, so we’re going to make that argument as well. And we did successfully last year, because they made this recoupment request for ACCU, so I’m hoping we should see the same.
So again, if you’re a network member with me, please contact me. And I’m going to encourage you, some of you, you’re thinking, Wow, I didn’t know this information was out there. That’s what we do with the H .J. Ross Network. We try to keep you ahead of the curve. So we want to make sure you’re always knowing what’s going on, not just continuing education, if you will, but also the up -to -date resources of what you need to deal with this type of recoupment.
So 365 days or going to be on the case law, but certainly something to push back. Until next time, my friends, take care.
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