September 2004

Medicare Q&A

by Dr. Jeffrey Shay

Every so often I like to review some basic insurance rules and concepts, especially Medicare. So here are some of the most asked questions about your favorite government program.

Question: Does everyone have to file Medicare claims? Can a chiropractor opt out of Medicare?

Answer: This is the question I am most often asked, and the answer doesn't make anyone too happy. If you treat Medicare patients, you must file a Medicare claim. There are only two criteria to consider: Did you adjust the spine, and did you charge for your services? If the answer to both is "yes", a claim must be filed with your Medicare carrier.

Chiropractors are not considered physicians under Medicare statutes, regardless of anything else you may have heard. Medical doctors are allowed to leave the Medicare program, but chiropractors can not. Some doctors have complained to me that they should have the right to stay out of the system; unfortunately, they have mistaken the United States for a free country.

Q: Can I have a private arrangement with a patient? I have a patient who just wants to pay me and forget the paperwork.

A: Absolutely not, and I'll tell you why. Not long after you do this, some clown will decide he can get his money back and submit a claim to an insurance carrier, even Medicare. Once he sends it in, it will eventually land in a Medicare office and you'll get a letter. The patient will not be in trouble, but you will be. I get regular calls from doctors involved in this exact scenario. The only more popular scam is the one on the Internet where the guy needs money to bring his family out of Nigeria.

Always remember that the public's desire to get well is only surpassed by its greed. I've also had doctors tell me that they've attended a seminar where the speaker told them how to run a cash system, with no insurance claims to file. That may be generally true, but not with Medicare patients. If CMS catches you, the speaker does not get fined, just the guys who listened to him.

Q: Why isn't there more information about Medicare and insurance taught in chiropractic schools?

A: I don't want to paint all of the schools with one brush, however, there is a tendency for some schools to be out of touch with actual practice conditions in the field. Also, there is often an arrogant attitude that considers field doctors to be outsiders.

Some years ago I represented my profession on the Medicare carrier board in Iowa. When I received new regulations from HCFA, I called Palmer College and offered to bring the information to students for their use. Palmer informed me they had experts on staff and there was nothing I had to say that would be of interest to any students on campus. I later found that none of the information was given to their students.

Q: Medicare doesn't pay much. Why should I have to keep records for such poor reimbursement?

A: In biblical terms, the Lord giveth and the Lord taketh away. Medicare gives little and can take away a lot. There is something called a post‑payment audit, where the carrier reviews your records for medical necessity. It then decides whether your records reflect the need for treatment. If not, they decide if they can take payments away from you. Medicare calls it a "review"; Stalin called it a purge. In future columns I will cover a few recordkeeping concepts, such as S.O.A.P. and P.A.R.T., that might afford doctors some protection against audits.

Although chiropractic organizations are not in agreement about recordkeeping standards, Medicare conveniently ignores this and sets its own standards. Your records are usually reviewed by nurses. Every carrier has its own chiropractic consultant, just like every picnic has ants.

Q: Why are there so few seminars about this stuff? Also, doesn't Medicare usually only go after bad guys?

A: Seminars are usually done on a popularity basis. Everyone wants a seminar about making money, not how to appease bureaucrats. Medicare denies auditing chiropractors out of proportion to their reimbursement. While chiropractic Medicare reimbursement amounts to only 1% of funds spent, the same cannot be said about post‑payment reviews.

Q: Medicare is a national program. Why are some doctors allowed more visits than others?

A: While Medicare is a national program, regional carriers have a great deal of latitude, therefore some states have more liberal standards for doctors. In Iowa the standards are fairly liberal, not so in California.

I am aware of one speaker who gives seminars on how to get paid more by Medicare, but doctors in many states find out that visit allowances can be much lower.

Q: I'm not registered with Medicare at this time. What should I do?

A: Call your Medicare carrier and they will issue you a provider number, as well as a packet of information. Even if you have never filed claims before, this is the best course of action. CMS does not usually investigate for past filings. Some information may be available from your state chiropractic association, although some may not be especially helpful to non‑members. In Iowa, however, all doctors are treated equally...both members and non‑members are ignored.

Q: When you choose to be a non‑par, does that take you out of the system?

A: No. Your Medicare carrier will give you an opportunity each year to choose how you can handle your participation. To be a "par" means that you agree to a slightly lower fee, but the Medicare check will be sent directly to you. So‑called "non‑pars" get paid a little better, and can also receive payment from the patient up front, but are still subject to a limiting charge. The level of reimbursement is a little better, but Medicare rules still have to be followed. By the way, Medicare pays pars at 80% of the allowed fee; doctors can still collect the balance from the patient, as well as any deductible.

Q: What is the difference between Medicare programs?

A: Medicare Part A is hospital insurance, this is made available to Medicare recipients at no charge. Medicare Part B is coverage for outpatient services, including chiropractic. Your patients pay for Part B coverage every month, with the exception of those who choose treatment in the VA system (veterans). Another exception would be railroad employees; they pay into a form of railroad Medicare with similar rules.

There is a newer program called Medicare Part C, which is Medicare coverage under a private carrier. This is something being pushed by the present administration, along with drug coverage. This program can offer extra services and benefits, while others can be eliminated, even if mandated by Congress (guess which one). Patients can trade in their regular coverage for a private program, a choice given to them once each year.

One exception: Medicare usually covers spinal adjustments only (manipulation, if you graduated from National University). Carriers can pay for chiropractic x‑rays under Part C, but not many will. Many companies offer such programs, e.g., Humana, John Deere, Kaiser, etc. Most of these programs are not chiropractic friendly.

Q: Where can I find more information on Medicare?

A: I cover Medicare and other insurance issues in this newspaper. When I envisioned the idea of a Medicare column 14 years ago, I approached several chiropractic groups, both state and national. I was told that there was no interest in Medicare information. The exception was The Chiropractic Journal, and that's why it's still one of the best sources for insurance information.

I am not particularly chummy with Medicare. I became an "expert" after I was audited by these dudes some years ago. (Note: If you want to know how it feels to be treated like a pariah, get audited and call your state association for information.) The Iowa Chiropractic Society told me to just pay the fine and not embarrass the profession. I won anyway, which tells you little about the state of chiropractic in Iowa.

I try to give helpful information about these problems in this column. I have found CMS representatives sometimes helpful, but usually not interested in handling problems for chiropractors.

A number of years ago I had a chance to question Gail Walinsky, HCFA director for President Bush, Part 1. My question was, "Why aren't chiropractors treated equally with other providers under Medicare?"

Her answer, "I didn't know Medicare covered chiropractic."

That in itself probably tells you more than you want to know.

(Dr. Jeffrey Shay, a graduate of Palmer College of Chiropractic and the WCA's 1996 "Chiropractor of the Year," is the World Chiropractic Alliance Director of Insurance Relations. He welcomes comments or questions regarding any insurance‑related subject appearing in this column. Dr. Shay is available to speak to your state or local organization. Contact him at 1300 Cedar St., Muscatine, IA 52761, or the WCA offices, FAX 480/732‑9313.)

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