Tag Archives: Medical Billing

Chiropractors Must Bill Medicare

28 Apr

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Chiropractic is one of the specialties that are required to have a contract in order to treat Medicare patients. If a chiropractor does not have a Medicare contract, they are required to refer Medicare patients to another chiropractor who does have a Medicare Contract. This is true even for chiropractic services that are non-covered by Medicare, such as maintenance care.

This rule can be found in Chapter 15 of the Medicare Benefit Policy Manual in Section 40.4. It states; “the opt out law does not define “physician” to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract.”
There has been a confusing notion in the chiropractic profession that chiropractors can have the patient sign an Advance Beneficiary Notice and bill the patient without being a Medicare provider. This isn’t true.

The No Opt Out Rule for chiropractors in the Medicare program means a chiropractor can treat a Medicare patient either as a participating provider or a non-participating provider, but either way, the chiropractor has one of the two contracts with Medicare; a participating contract or a non-participating contract.

A Medicare participating contract means the chiropractor has physically signed a contract with Medicare, agrees to abide by all the rules of the program, bills Medicare and accepts assignment from Medicare. A Medicare non-participating contract means the chiropractor has physically signed a contract with Medicare, agrees to abide by all the rules of the program, but has a choice whether or not to accept assignment.

There is one more catch, a non-participating Medicare provider is still limited by how much the patient may be charged. There is a limiting fee schedule whereby the chiropractor may only bill the Medicare patient up to 115% of the allowed Medicare fee even if the chiropractor does not accept assignment and the patient receives payment directly from Medicare.

There is a good handout published by CMS called “Misinformation on Chiropractic Services” that covers this rule and many others. For a copy of this handout, search for it at http://www.cms.gov and it will be readily available. If you are unable to find it, please email bonnie@billingbuddies.com with the subject line stating; “Misinformation on Chiropractic Services” and you will receive a return copy.

Billing Buddies ® Bullet Points is brought to you by Billing Buddies. Visit us on the web at http://www.billingbuddies.com. I’m your host, Bonnie J. Flom. I have 34 years of medical billing experience and am a Certified Medical Reimbursement Specialist through the American Medical Billing Association. If you have any questions or comments, please email bonnie@billingbuddies.com or call or text 612.432.2366. Our goal at Billing Buddies is to help optimize and expedite our providers’ reimbursement so they are better able to serve their clients. If you should need medical billing or training services, please contact us. Have a great day and happy billing.

 

Replacing Modifier 59 with X-Codes

28 Apr

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Are you still using Modifier 59? CMS replaced modifier 59 on January 1, 2015.

First, what is Modifier 59? Modifier 59 is used in medical billing to override the National Correct Coding Initiative (NCCI) edits which CMS created in the first place. Some services are included or bundled into other services and should not be billed separately. However, there are circumstances where it is appropriate to bill the services separately and the 59 modifier has been used historically to tell insurance companies this is one of those circumstances.

You can find the complete details on the creation of the new codes at http://www.cms.gov by searching for the MLN Matters article MM8863. Please review this article in detail to gain a complete understanding of the changes.

The new modifiers used to replace the 59 modifier all begin with a letter X.

XE = Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter,
XS = Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
XP = Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
XU = Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

CMS will continue to recognize the 59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many circumstances, they may selectively require a more specific X modifier for billing certain codes at high risk for incorrect billing. If you haven’t done so already, it would be a good time to review and adopt the X modifiers.

Billing Buddies ® Bullet Points is brought to you by Billing Buddies. Visit us on the web at http://www.billingbuddies.com. I’m your host, Bonnie J. Flom. I have 34 years of medical billing experience and am a Certified Medical Reimbursement Specialist through the American Medical Billing Association. If you have any questions or comments, please email bonnie@billingbuddies.com or call or text us at 612.432.2366. Our goal at Billing Buddies is to help optimize and expedite our providers reimbursement so they are better able to serve their clients. If you should need medical billing or training services, please contact us. Have a great day and happy billing.

 

Effective Follow-up Processes for Medical Billing

25 Apr

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Following-up on unpaid claims can be one of the most frustrating parts of medical billing. Follow-up really trails the old 80/20 principle. 80% of the claims get paid the first time, but the 20% that don’t get paid the first time takes 80% of your time. The trick to making follow-up more streamlined and efficient is to categorize your outstanding claims within three buckets; contract payers, non-contract payers, and self-pay balances.

Let’s start by reviewing the difference between your contract payer and non-contract payer claims. Contract payers’ claims are claims that you physically have a signed contract with the insurance carrier. Most clinics have between 6-12 signed insurance contracts. For example, a typical clinic would have a Medicare, Medicaid, BCBS and perhaps a couple HMO contracts. Whereas, if you look at any insurance payer list from a clearinghouse, you will see there are thousands of insurance companies; which tells you there are potentially dozens of non-contract insurance companies to which you may bill.

Why does this make a difference? Well, if your clinic has a signed contract with an insurance company, both the clinic and the insurance have mutual obligations to one another. The clinic has agreed to bill a claim, write-off contract adjustments and follow-up on unpaid claims. The insurance has agreed to adjudicate the claim, pay the clinic directly and respond to claim inquiries.

Now, contrast that with a non-contract insurance company. Non-contract insurance companies are not contractually obligated to pay the clinic directly or even to respond to inquiries about claim status. For example, two larger insurers that will not respond to non-contracted clinics are Medica and Blue Cross Blue Shield.

Understanding the difference between contract and non-contract insurance companies is the secret to saving time in the follow-up process. Given the fact that non-contract insurance companies do not have an obligation to respond to the clinic’s request for payment, the clinic is really doing courtesy billing on the patients’ behalf. So, after 30 days, if a non-contract insurance has not paid, you would be wise to bill the patient directly and save your time to follow-up on contract payers where you are contractually obligated to resolve outstanding balances.

Finally, to wrap this up, make a follow-up flow chart for each of the three buckets of outstanding claims; contract, non-contract and self-pay.

If it is a contract payer, at 30 days, call the payer or investigate the claim online. You are looking to resolve this claim as quickly as possible by determining if the balance is due from the insurance, the patient or if the clinic needs to return information. If the balance is due from the insurance, call the insurance and document the Person, Place, Phone number you called, along with the Action Needed and Action Taken. Get a commitment from the insurance to pay and add a note to your system if the balance is due from the insurance. If the balance is due from the patient, send the patient a statement and follow your self-pay flowchart. If the clinic needs to return an item, do that as fast as possible and document it.

If the balance is due from a non-contract insurance, at 30 days, send a statement to the patient and follow your self-pay flowchart.

Finally, your self-pay flow chart should have you sending no more than two regular statements to a patient and then sending a pre-collection letter and turning the claim to a collection agency. Statistics show that if a claim isn’t paid by a patient within 90 days, the likelihood of it getting collected is slim without the help of a collection agency.

Billing Buddies ® Bullet Points is brought to you by Billing Buddies. Visit our website at http://www.billingbuddies.com. I’m your host, Bonnie J. Flom. I have 34 years of medical billing experience and am a Certified Medical Reimbursement Specialist through the American Medical Billing Association. I can be reached by email at bonnie@billingbuddies.com or you can call and text me at 612.432.2366. Thank you for listening and happy billing.