Dr. Evan Gwilliam (SVP, Practisync) and Marc Abla, CAE, discuss rising VA Community Care denials tied to the AT modifier, what may be required, and the potential impact on chiropractic care and patient benefits.
Transcript:
Marc:
We’ve seen an interesting dynamic regarding the VA community care program across the country, and it really compelled us to do some digging. And so, Dr. Gwilliam and I have taken some time. Actually, Dr. Gwilliam, more than me, to be honest, has done a bunch of digging and research and digging up some documents and policies, and the reason why we started seeing this and started doing this research was because we have found out that TriWest, and just to kind of get everybody on the same page, there are two processors, if you will; there are two carriers that process VA or Veterans Administration Community Care Program claims. You have TriWest, and they handle the western half, if you will, of the United States, and then you have Optum that handles the eastern half. For us here in Illinois, we’re Optum in the VA Community Care Program, and so what we found was in the West with the TriWest that all of a sudden we had some doctors out west that were getting denied for not including the AT modifier, and so we did some digging. Doctor Gwilliam, what did you find when you did your research?
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Dr. Gwilliam:
Yeah, so Medicare forever, not forever, but for a very long time, has required chiropractors to append the AT modifier to chiropractic manipulative treatment codes. It means active or corrective treatment, and without it, it means the patient is not receiving active or corrective treatment, which is not covered under Medicare. And so, in order to have a claim with a chiropractor manipulative treatment code considered for payment. The AT modifier must be attached, and what that communicates to Medicare again is this patient, if you go look at their record, it has a story. There is functional loss. They’re receiving the service with a specific outcome in mind, there’s functional gains that can be tracked. This is active or corrective treatment, not maintenance care. That’s what you add that modifier to communicate that. And what we discovered was that Triwest and Optum have both stated, off and on through the years, that they adhere to Medicare’s billing policies, and therefore that rule around the AT modifier and what it indicates and what must be documented-all of that applies to the VA claims. And kind of, I might go out there and say, always has. And the difference, though, is what we started seeing in recent months is that it’s being enforced, and so that’s the dilemma here that we want to make sure everyone understands. So you know how to make sure you get paid for the work that you do.
Marc:
Yeah. So I think it’s there’s a couple of things that we have to unpack with this that I think are really critically important. One is, you know, hey Marc, who cares? That’s TriWest who’s given the denials. Optum doesn’t. Well, I think the better answer to that is Optum doesn’t today, and so what we have found and what we know for a fact is that Optum will accept the claims with the AT modifier, and so there is no penalty for including the AT modifier directly on the claim form. I’m going to add now the second part of that, which is the second thing we have to unpack, which I think is actually critically important from from an advocacy organization and from conversations that I’ve had with a number of people across the country, specifically related to this policy, is we have a fundamental problem with them adopting the AT modifier as a required element, and here’s why: their policy, talking their meaning the VA’s community care program policy, is different than Medicare’s when it comes to, if you will, maintenance or sustaining care for someone who potentially has reached an MMI or maximum medical improvement. And so Medicare’s definition and what they pay for is different than what the VA does, and so we have a fundamental problem with adding this specific requirement. I know that they have claimed that they that they follow Medicare, but their policies actually are different, which means that you’re able to give different care to a veteran who is under the veteran who you know has who’s met all the protocols and requirements for the VA community care program, but the problem with it is is that sustained care that that the care after maintenance I guess is is the general term that we always use right. We have a fundamental problem with that because if they’re going to say that they pay for it, but then require an AT modifier. It puts you in a really difficult spot of appending an AT modifier for a case that isn’t active treatment, right? But still meets their payment protocol requirements that are in their guidelines. And so there is a fundamental breakdown in this. And I will tell you that we’re having significant conversations with key players. And we’re talking with multiple national organizations that are tackling this as well. We believe that it is incorrect. It’s an incorrect application of the Medicare policy. So it’s something that we have to consider through this process. But we want you to be aware if you start seeing denials, what’s going on and what’s up.
Dr. Gwilliam:
But I would. I’ll also throw in there, though. But in the meantime, while the care is truly active, corrective treatment as required by Medicare, if you can, and it’s happening this way, document clearly that it is active treatment and not the type of maintenance when it’s present. The documentation is critical. The separate issue that you’re talking about, hopefully we’ll figure that out too. But if it’s there, by all means, explain it, document it, make sure the record tells that story clearly and well, and the modifier is used, and it all fits, and there should be no problems with those. And then we’ll deal with this other issue as we continue to work through the you know the hoops.
Marc:
Yeah. So be aware, be cognizant of what’s going on. And if your treatment is absolutely an active treatment and would fall under that guideline, you can add the AT modifier. And just to ensure, even though we’re Optum and they’re not enforcing it today, we believe that could change. But we know it is absolutely being enforced in the West through Tri West, and so we just want you to be aware of what’s happening, and also the things that we’re doing, and we are working on seeing if we can get this ship righted in this arena. So hopefully this helps you out. Thank you, Dr. Gwilliam, for joining us again this week. We’ll catch you next.
