Although I have written about Medicare many times in this column, it should be remembered that many doctors and their staffs are new to this system. As a result, this month I'm going to review Medicare from a beginner's standpoint.

First of all, Medicare is not an insurance. It doesn't pass the duck test, i.e., it may look like a duck and quack like one, but it isn't a duck. Medicare is a federal entitlement program. Unlike insurance, it has to accept anyone who qualifies for coverage — anyone over 65 and disabled individuals who quality.

Being a federal program, it is exempt from state supervision. This means that your state insurance commission has no jurisdiction in this area, no matter how badly you think you got stiffed on your last claim.

There are three Medicare programs: Part A, hospital coverage; Part B, outpatient coverage for providers, including chiropractors; and Part C, managed care (that operates under different rules). Chiropractic coverage became a reality in 1975.

Your patients automatically get Part A coverage at no extra cost when they enter the Medicare program, sort of like the free pickles on your cheeseburger at McDonalds (but it's actually figured into the cost).

Most of your patients pay a monthly fee for Part B, which works in your office.

Some areas offer Part C, which is alternative outpatient coverage. We don't have Part C in Iowa, since fees are so low here that managed care isn't necessary. It would be like importing longhorns into Texas. Personal income here is similar to that in most third world countries (I'm surprised bananas don't grow here).

I have never liked the term "provider." It's a sterile term that lacks dignity, and reminds me of similar titles awarded by businesses. For example, the guy with the earring through his nose at the discount store is a "team member." The one with the broom and the biker's tattoo is an "assistant manager." And the mob's just a bunch of "good fellas" who don't kill anymore, they just "eliminate" or "terminate with extreme prejudice." Or was that the CIA?

When you first set up your practice you have to sign a Medicare contract with your regional carrier. If you don't know the name of the carrier, you can find out from the state chiropractic association, or pick up your newspaper and see which insurance company is threatening the most chiropractors.

Each year you will be given the choice of "being a participating or a non-par provider (I'll cover this matter in upcoming columns). It's a bit like choosing between what's in the box or what's behind the curtain, but there's a bad odor in the room that could be coming from both places.

A note about Part C. This is a program operated for the government by private carriers, and they are allowed much more leeway in coverage and fee-setting. This is also the entity that is being sued by the ACA, with the support of the WCA and other chiropractic groups due to discriminatory practices.

As in the Part B program, manipulation is covered. The carrier has been using PTs and medical practitioners to deliver this service, thus cutting out chiropractors. Our position, simply put, is that we should be the primary providers of adjustments, as anything else is a sham.

It's hard to believe that the government would actually cheat a group of health care providers who are just trying to remove nerve interference. It's also hard to believe Lee Harvey Oswald could group three shots in six seconds into a moving motorcade with an old Italian rifle usually reserved for pounding on tent stakes, and then reappear in a movie theater in time for the feature.

Medicare is a national program, but its rules vary state by state. This is because the carriers are given a good deal of latitude in setting rules, and are even encouraged to do so, because regional conditions are variable. Iowa, for example, is rated last in the 50 states in reimbursement, even though all U.S. citizens pay the same amount into the system. By some amazing coincidence, the states with the highest reimbursement levels also have the most electoral votes at election time.

Of course, the government would never show favoritism, but someone apparently forgot that Iowa still appears on most Rand McNally maps somewhere between Minnesota and the Ozarks. Out patient reimbursement level is $2,000 below the national average annually. This state has one of the highest populations of elderly, and the most over age 85.

The only chiropractic service covered by Medicare is the adjustment (or manipulation, depending on which chiropractic association you joined). For many years we were required to take a subluxation x-ray to prove necessity for treatment, but this statute was dropped in 2000. Now treatment necessity is based on your recordkeeping. The bad news is that your records are usually reviewed by nurses, which is on the same order as having your car repaired by Roto-Rooter.

Carriers are required to have a chiropractic consultant available when requested. However, they get to choose the consultant. This is similar to the system where the Supreme Court picks the president, but you can always appeal to Jeb Bush. While I would not want to cast aspersions on all chiropractic consultants, the popularity of some rates slightly below that of Enron executives.

An important thing to remember concerns filing requirements for Medicare. All treatments involving spinal manipulation must be sent to the carrier. There are artificial treatment limitations that vary state by state, with some states allowing as few as 12 visits per year, while others allow about four times that number. If you feel that the patient has accumulated more visits than may be paid for, it would be wise to have the patient sign a disclaimer indicating his or her awareness of such. Note that Medicare will only pay for symptomatic treatment, not maintenance treatment nor wellness visits.

Still, whether visits will be paid for or not, they must be filed. There are some exceptions. Any visit not involving spinal manipulation is not included in this dictum. Also, any time another insurance company may pay for the entire cost, filing is not necessary. An example of this is when a Medicare patient is involved in an automobile accident and the bill is paid for by the auto carrier, e.g., State Farm.

One other note. Medicare has been performing post-payment reviews, and your odds of being audited depends on which state you practice in. At present, Pennsylvania chiropractors seem to be the victims of most audits. These audits are being used to force doctors to refund payments received for visits considered unnecessary, under the aegis of not being supported by treatment records. It doesn't matter if you think the work was needed, or even if your patient thinks the treatment was warranted.

The bottom line is the carrier conducts the audits and has a quota to meet, so guess how often you win. I'm not imagining the quota. I was given the information by a carrier representative. The best defense is good recordkeeping, something covered regularly in this column. These audits started in earnest in Iowa about six years ago.

Speaking of Iowa, regular readers no doubt remember that I entered the state quarter contest several months ago. Each state is represented on a quarter with a chosen design. New York has the Statue of Liberty, Massachusetts has a Minuteman, and South Carolina has a palmetto. Since the public was allowed to submit designs, I sent one in with a portrait of the three Palmers and a chiropractic notation. As I expected, it was rejected and I was sent their version of a Dear John letter.

The governor's staff has been frustrated by some of the submitted mottoes and designs, such as "Baja Minnesota", "More Hogs than Humans", and "Honk If You Like Corn," as well as a Grant Wood portrait showing a farmer, his wife, and his trusty pitchfork.

I should mention that Iowa not only has the lowest Medicare reimbursement, but it also is the only state showing a net population loss over the period of the last century. In this spirit, I sent in a new design showing a crowd of people leaving Des Moines, and a giant hand on a light switch, with the inscription, "Turn Out the Lights, the Party's Over."

My wife has said that the government will probably hire an assassin to take me out. I claim that it's just truth in advertising.