Opting Out of Medicare
Mastering Medicare: When Opting Out is not an Option
Editor’s Note: Originally posted on 9/22/2016. Updated with OIG’s 12/7/2016 Statement Regarding Gifts of Nominal Value (full text here).
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing, and just about the time you think you have it figured out, you receive a notice that suggests you don’t. I travel across the nation most weekends attending chiropractic conventions, and the topic of Medicare comes up frequently. The struggles of treating Medicare patients varies from low reimbursement rates to when a patient should sign the ABN form. It doesn’t help that, as a provider, you can often receive conflicting answers to even the simplest questions. That is if you have the patience to sit on hold for hours to speak with a live person at CMS. All of the chaos associated with Medicare has even the most seasoned chiropractors asking themselves if they really want to continue treating Medicare patients.
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Currently, 44 million beneficiaries, some 15 percent of the U.S. population, are enrolled in the Medicare program. Enrollment is expected to rise to 79 million by 2030. Only one in 10 beneficiaries relies solely on the Medicare program for health care coverage, according to an AARP Special Report. The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US, do you really want to limit your patient base?
Unlike MDs and DOs, chiropractic physicians may not opt out of Medicare. The bottom line is that IF you intend to treat a Medicare patient, you must be registered with Medicare. Medicare has a mandatory claims submission rule. Hundreds of providers over the years have told me that they require that the patients sign the ABN form on the very first visit and have the patient pay them directly. That is considered an “improper use” of the ABN, and it just doesn’t work like that. The ABN form should be used to notify the patient when the patient receives care that is not covered by Medicare, not because you want to avoid filing Medicare claims. If you choose not to submit claims to Medicare, then you are making the decision not to treat Medicare patients and should be referring them to the closest Medicare registered provider in your area.
Even worse than not filing Medicare claims for patients is giving away or discounting non-covered services below “fair market value.” Offering Medicare patients anything more than $15 off on a visit, or a total of $75 in a year, is a potential inducement violation. The OIG published a Special Alert Bulletin advising against discounts that could be considered an inducement and tagged the offense with up to $10,000 per occurrence.
One of the greatest frustrations with Medicare is denials. If you are receiving multiple denials from Medicare and not getting paid at all, then make sure you are using the proper modifiers. Do they understand the difference between acute, chronic and maintenance care? Are you coding your acute care with an “AT” modifier? Is your documentation in order? The great news is that there are only 3 codes covered by Medicare and many consultants across the country can help educate you and your team on how to overcome the headaches of denials and get paid on medically necessary care. Once you have mastered the few things you need to know about Medicare as a chiropractic physician, the process will no longer feel overwhelming and confusing for you and your patients.
Although we don’t have the freedom and flexibility of opting out, we are also relieved of having thousands of codes covered by Medicare. I choose to think of the limited nature of covered services for chiropractic care with a “glass half-full” mentality. Using ChiroHealthUSA in my office has allowed me the flexibility to create care plans that benefit my patients while keeping their out-of-pocket expenses reasonable for their non-covered services. And I DON’T have to worry about inducement violations! I’m being reimbursed for their adjustments and getting paid for the additional services that are not covered by Medicare. With 90% of may patients taking advantage of rehab and therapy in my office, it is a win-win for both of us.
To learn more about how ChiroHealthUSA can help you and your Medicare patients, go to https://www.chirohealthusa.com/providers/grow-your-practice/.
Dr. Ray Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation, and compliance. He has served as president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a Fellow of the International College of Chiropractic. You can contact Dr. Foxworth at 1-888-719-9990 or info@chirohealthusa.com. To learn more about how ChiroHealthUSA can help you and your Medicare patients, go to https://www.chirohealthusa.com/providers/grow-your-practice/.
