NGS Takes Over Medicare in Illinois: More of the Same?
On September 7, 2013, National Government Services (NGS) took over the contract as a carrier for processing claims and adjudication of Medicare in Illinois, Wisconsin, and Minnesota. Wisconsin Physician Services (WPS) was our former carrier for as long as I can remember. It is just a change in carriers, right? After all, it is still Medicare. Or is it?
The Centers for Medicare and Medicaid Services (CMS) is the mother of Medicare, but she has given more and more autonomy to the carriers to determine how they are going to administer Medicare in their regions. The medical policy for each carrier is laid out in the Local Carrier Determination (LCD). Our region is now known as the Medicare Administrative Contractor (MAC) Jurisdiction 6 (J6). It is imperative that every provider understand the policy and nuances of their carrier. Thus, we should pay close attention to the NGS (our MAC) LCD. While studying the NGS LCD, certain important changes begin to surface. I will attempt to outline some of the facts in this article. Look for clarifications as the ICS gets answers to some of our questions.
Local Carrier Determination (LCD)
You can find the LCD for Chiropractic at the website for NGS at www.NGSMedicare.com. I suggest everyone go to the website to download the LCD and actually read it. The LCD ID number for chiropractic in Illinois is L27350.
If you file claims electronically, then you or your billing company will have to enter in the correct contractor number on the claim. The contractor number is sort of the electronic address that tells the software where to send the claim. NGS claims are going to be handled in Indianapolis, Indiana, and their contractor number is 06102. If you are sending in paper claims, then you will send the claims in to:
National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475
The most significant change is with the diagnosis tables. The diagnosis table determines which ICD-9 codes will be covered for Chiropractic services. If you use a code outside of those listed in the LCD table, your claim will be denied. When I did a comparison of the codes listed in the table for WPS and compared them to those for NGS, I found that we had lost 38 codes (one-third fewer than with WPS). In essence, this decreased the covered scope of practice for chiropractic care in Illinois Medicare. The Carrier Advisory Committee (CAC) representative for Illinois and the ICS Medicare Committee is investigating this further. You can find the diagnosis table in the LCD. If you are a member of the ICS, we sent you a list of the diagnosis table and a list of the codes that have been eliminated (http://ilchiro.org/news/138520). If you are not a member of the ICS, I think it is another reason to join!
Advanced Beneficiary Notice (ABN)
The ABN is a notice given to the patient to notify them of liability. In other words, it tells the patient that they are responsible for payment of the bill if NGS denies any of the services. Some of the services we perform in Medicare will never be covered; exam, x-ray, therapy and so forth. This can be placed on the ABN form voluntarily. Under WPS, we were not to have options given to the patient as to if the services are to be billed to Medicare. Under NGS, that has changed back to mandatory options on the ABN.
A modifier is a method to let the carrier know that something is different with this service. In Medicare, we always taught that the AT modifier is for “active treatment”, GA modifier indicates that a signed ABN is on file. The GA modifier is used for maintenance care, which is not a covered service under Medicare. If you used the ABN for a non-covered service, then you would append the GYGX modifiers to the service. The ATGA modifier is used for active care in which the provider has a “genuine doubt” that the service will be covered, although the provider still considers it active care. This was typically used when you had a higher number of visits during the year and you felt that it was getting in the danger zone for denials.
NGS stated that they have removed the Utilization Guidelines for Chiropractic Services. You will notice that no longer are their categories for the diagnosis, such as short-term treatment, moderate-term treatment, and long-term treatment. Since the utilization guidelines have been removed, there are no longer any instances of “too many visits” according to NGS. In a Medicare world with many shades of gray, NGS is black and white on this matter. Unfortunately, that leaves us, the provider vulnerable. If we feel the care is active and NGS construes it to be maintenance, then it will be denied on an audit. If you do not have an ABN form signed, then you will have to refund the money. This is true whether you are a participating or non-participating provider. The Carrier Advisory Committee (CAC) representative for Illinois and the ICS medical committee is investigating this further.
As we begin to experience life under NGS, other changes may surface. I have always said that nothing in Medicare ever stays the same. To explain the solutions to the above dilemmas and other questions, you may want to attend classes sponsored by the Illinois Chiropractic Society for the most accurate answers available. The ICS will be offering Medicare classes in the coming months, including at the National ICS convention in Naperville.
Dr. Fucinari and the ICS will be presenting several classes in the coming months to aid the doctor and staff in correct compliance procedures. For an updated schedule of classes and locations, go to www.illinoiscme.com or www.AskMario.com. Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. For further information on compliance audits, manuals or record reviews, please contact Dr. Fucinari at Doc@Askmario.com