When Opting Out Isn't an Option

Not long ago. we heard from a panicked DC who had just received a call from Medicare. Ecck! They asked him why they had begun receiving itemized statements from his patients when they couldn't find him registered in the system. He told them that his particular style of chiropractic was not classified as a chiropractic manipulative treatment (CMT) because he was more of a sports chiropractor. He felt that he had "opted out" of Medicare. His logic was that most of the patients in his practice were a younger, more active clientele of athletes and active adults, and he had very few Medicare patients. So mostly, he felt he wasn't really providing Medicare-covered sen ices. Evidently, these patients thought he was. The key word here would be "mostly." By the time we re­ceived the e-mail, this poor guy was in a panic, and for good reason. Chiropractors can choose to be participating (par) or be non-participating (non-par) providers of Medicare, but opting out isn't an option. He had been treating Medicare-qualified patients who thought they were seeing a typical chiropractor who was enrolled in the Medicare system. Now they were seeking reimbursement from cither Medicare or their secondary insurance on their own. As a result, the chiropractor in question was receiving letters and calls from Medicare telling him that he wasn't using the proper modifiers, and the secondary insurances w ere demand­ing an "opt-out letter." which was something he wasn't even legally allowed to do. He was confused and distraught, and we were just plain worried. By the time Medicare is sending you notices sniffing for more info and wondering why in the world your patients arc sending in their bills, you're not just in hot water, you're gasping for air. A discouragingly large percentage of DCs still believe they can "opt out" of Medicare and demand cash from Medicare patients. That is not acceptable or legal. Even if you are a "non-par" provider, you still must be equipped to be able to bill Medicare on behalf of the patient if they ask you to do so. This is as tmc of statutorily noncovcrcd sen ices as it is of covered chiropractic manipulation. The rules arc simple: DCs must bill Medicare directly for all covered sen ices and for the statutorily excluded sen ices if the patients ask them to do so. such as for denial in order to submit to a secondary insurance. Why? If a patient were to receive an excluded sen ice. such as an exam, the secondary carrier might pay if Medicare denied the claim. How ever, if your practice doesn't have the proper Medicare number, then vou can't submit the claim in the first place. Medicare can"t deny the claim because they will never see the claim. Thus, there is no way to send the claim on to a secondary payer. Similarly. DCs often believe that if they have an Advance Beneficiary Notice (ABN) signed by the patient, everyone is in the clear. Again, though, if a chiropractic practice doesn't have a Medicare number, it's not entitled to even use the ABN form: the practice is not in Medicare. Here's the straight scoop from the American Chiropractic Association (ACA): DCs can absolutely choose not to accept Medicare patients, or they can choose to limit the number of Medicare patients they accept into their practices. However, if they do choose to sec and treat a Medicare beneficiary, as our friend did. they must be enrolled as a "non-par" provider and must submit claims to Medicare on behalf of the patient. Violations of this requirement can bring about penalties of up to $2,000 for each infraction. It isn't pretty. Last September's changes for HIPAA omnibus gave patients unprecedented rights and control over their protected health infomiation (PHI). So if you're a chiropractor who doesn't have a Medicare number and a patient wants to be treated with the understanding that the office can't bill Medicare, there's only one way around it. Patients must voluntarily restrict their protected health information by exercising their rights under HIPA A and agree tliat they understand—in writing—that neither doctor nor patient will be able to submit bills to Medicare. Be warned, though, that under these new HIPAA rules, you must follow the patient's direction not to share infomiation with Medicare, proper Medicare number or not. Our friend got into trouble because, in Ms mind, he absolutely believed that he was not providing a coverable service—i.e.. a chiropractic manipulative treatment—but instead something closer to joint mobili/ation. which he was coding as 97140. The catch here is that if that were indeed tnic. then by law—since by his own admission he isn"t providing a coverable service under Medicare—he would have to turn patients away and set up a front desk script to explain why. Alternatively, he could get a number and submit to Medicare if asked to do so. Except for simply waving goodbye, the front office staff then would have to offer to refer patients to another DC who provides a coverable service, participates with Medicare, and can bill on the patients" behalf. Again, the only way these pa­tients could stay with the original practice is by using their new HIPAA rights and agreeing to restrict the practice's ability to bill Medicare or any other carrier. Further, patients would have to agree that even though they w ill get a receipt, they could not send it to Medicare on their own. There's plenty of room for trouble here. Even with great front office scripting and patient education in place, which clearly wasn't the case here. DCs ultimately have no control over what patients do. You can sit them down, script, and straight talk until you're blue in the face, but those patients could easily go ahead and submit claims to Medicare all the same, just as this DCs patients did. There's a better way. though. If you plan to sec Medicare patients at all. just get a registered Medicare number. When a Medicare patient receives active treatment, submit the bill and have proper documentation. If the patient receives only statutorily noncovcrcd treatment, such as manual therapy or evaluation and management sen ice. then get payment for those sen ices in cash. If you do provide a covered CMT. submit the bill. If you provide maintenance care, get an ABN signed and collect cash for the adjustment. Make sure you submit at least one bill to Medicare each \ ear. though, or you will be placed on inactive status and land yourself in the same hot water as you would without an active Medicare number. The very worst thing you can do is ignore the rules, see Medicare patients randomly, and ask them to pay cash outside of the system. Wc"rc not fans of practices that try to operate outside the rules because even if patients say that they want to pay cash, inevitably they or their famih members or accountant will wonder at some point why the bills haven't been submitted. We have never seen this end well. Don't want to see Medicare patients? Then don't see them. However, we beg you to get a registered number as a "non­par" provider. You just might save yourself tens of thousands of dollars and a whole lot of heartache. Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and. since 1983. has been providing chiropractors with reimbursement and compliance train­ing, advice and tools to improve the financial performance of their practices. Kathv is known as one of our profession s fore­most experts on Medicare andean be reached at (855) TEAMKK1C or infodjcmcuniversity.com