Here are some answers to the questions that many of you ask in hushed tones before or after my seminars or behind the veil of an email.  Most are in respect to the perennial challenges chiropractors face on one topic: Medicare.

Please sit down and listen carefully because you may not like what you are going to hear.  In fact, I have no good news to bear whatsoever.  Perhaps I should title this my “Annual Medicare Doomsday Warning” (maybe semi-annual is better and more necessary) because our challenges in the Medicare arena have risen to the levels of a state of emergency or potential disaster waiting to happen .  Anyway, here it is:

The Par vs Non Par Debate or Non-Debate

• With all the talk of audits and the fear of having to give back your hard earned dollars, many ask if going Non-Par would be a safer or better option.  First, let me clarify that Par or Non-Par status is simply a payment issue.  Any talk you have heard in connection with par status and audit-protection is theory at best and dangerous rumors at the worst.  Fact: Par providers are paid 5% more than Non-Par.  Fact: Non-Par providers can collect upfront from their patients if they do not accept assignment.  However, NEITHER situation provides any guarantee or protection from audits!  Here’s why: you are subject to the same rules in both camps.  See the ACA’s web page on Medicare Myths for further clarification. Recommended Solution? Make the financial decision on how you want your payments to be processed and choose your par status accordingly.  To ready yourself for audits (by Medicare or any other payer), check out my program: How to Prepare Your Chiropractic Practice for Recovery Audits.

Billing Medicare for Chiropractic Services

• If you provide chiropractic adjustments to a Medicare patient, you MUST submit claims to Medicare. CMS requires that you bill all covered services rendered to Medicare patient.  The spinal adjustment is a covered service;  active treatment is reimbursable. Yes, I understand that this means you may provide other services that Medicare will never pay for. I didn’t make the rules so don’t whine to me.  (If you want to get out, make sure your will is updated & see below.)

“Inconceivable!”  you may cry. Unfortunately, truth is stranger than fiction. Alas, valiant chiropractic knight, fair chiropractic maiden, we must concede defeat and –

But wait!  A small light at the end of the tunnel!!!

The Exception to the Rule

As with much of life, there is an exception to every rule. Here it is:

• If you perform a chiropractic adjustment that is for Maintenance care (which will not be reimbursed anyway), your patient can agree to Check Option 2 on the New ABN which releases you from the obligation of billing Medicare for that Maintenance adjustment.  This is the only exception to the above rules and ONLY applies to billing adjustments for Maintenance care.

Opting Out of the Medicare System (Or Not)

For those of you who don’t like Medicare, you probably have considered “not playing their game.”  Unfortunately, they have rules for you too.  Namely:

• Chiropractors cannot opt out of Medicare. As DC’s we have a “special” status in the Medicare system; we are neither full-fledged physicians (like MD’s) but we are also more than practitioners (like PT’s).  To quote the Medicare Benefit Policy Manual “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.” (Ch 15, Section 40.4).  Basically, this means you cannot leave the Medicare family.  I know that sounds a lot like the mentality of certain “agreements” made with gangs, loan sharks, drug dealers or the mob, it is an accurate comparison. The coffin, provided you are in it legitimately and permanently, is one notable exception to “opting out” of Medicare. But at that point, your participation in Medicare is so limited it is probably a non-issue.

• Whether or Not You Think You are In Medicare, You are in Medicare. Remember that lovely little thing called the NPI that was instituted a few years back?  With this number, each and every payer can (and does) track your every move – including Medicare.  So, even if you are blatantly trying to ignore Medicare by “staying under the radar” and providing all your services in exchange for chickens, lawn care or for free out of the kindness of your heart, IF you have provided a chiropractic adjustment to a Medicare beneficiary you are in the Medicare system.  Or at least you should be.  Therefore, the fact that you didn’t complete a provider application, that you don’t submit any claims to Medicare or that you can’t find anything from Medicare that indicates you are a provider, you are still subject to Medicare rules and regulations.  Practically speaking, you have provider services to a Medicare beneficiary via a “private contract” (as defined in the Medicare Benefit Policy Manual, Ch. 15, Section 40.7).  Unfortunately, as a chiropractor you are not allowed to have a private contract with Medicare patients because only those who can opt out can legally establish a private contract  Therefore, you are in Medicare, but not playing by Medicare’s rules.  Likely, you are in trouble as well and you should fix this situation immediately, as Medicare penalties are not for the faint hearted.

For those of you who have been operating inefficiently, illegally or somewhere in between and have been brought to light by this post, I don’t need to hear your confession or defense of why you have been in the dark about this.  Instead, it may be time to take concrete steps towards more closely evaluating your billing department (whether in-house or outsourced), as they should know and/or catch some of this for you.  For some of you, it may be time to shop for a new staff member or billing service.  Check out “How to Oversee Your Billing Service or Staff” for some concrete strategies and tips in this area.

For those of you who have additional questions, need some clarification or are just plain confused, I would encourage you to post your questions/comments below and I will answer the most popular ones via another blog post.

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