ore often than not, doctors decide about insurance participation based on the horror stories they hear from their friends. It's not unusual for both new and seasoned practitioners to throw up their hands at the prospect of dealing with insurance companies on behalf of their patients. More doctors are also concocting ways to skirt working with Medicare. None of this is necessary. Insurance coverage is a treasured commodity that patients feel compelled to use because of the premiums they pay. A typical practice working within the boundaries of compliance and proper documentation and billing should have no problem working with third-party payers. To cultivate a healthy doctor-carrier relationship, focus on these five areas:
- Ensure You are Properly Credentialed
- Understand the Expectations and Limitations
- Know the Medical Review Policy
- Bill and Code Correctly
- Firmly Follow Up
Ensure You are Properly Credentialed
Every carrier has rules about who does what to whom and who gets the $5, as they say. There are two kinds of relationships possible with a typical carrier: a participating or a non-participating agreement. This is delineated by the rules associated with the contract signed. Medicare, however, is a different animal: Whether participating or non-participating, you must be registered with Medicare to see any Medicare patients. That means you have applied for provider status and are legally allowed to see Medicare patients. Chiropractors have an extra layer of regulation, in that if a chiropractic manipulative treatment (CMT) code is provided, you must be able to bill it, and without being registered with Medicare, participating or not, you can’t bill without a Medicare number. And yes, we are all aware of the nightmare getting registered with a carrier, and Medicare in particular, can be. Here is a story related by KMC University Medicare Reimbursement Specialist Naomi Chance, CPC about a recent experience she was involved in:
“It was in the summer of 2011 when a young doctor contacted me about the numerous and complicated problems he was having getting his Medicare Enrollment Applications approved. He had completed every single form required, submitted all sorts of documentation, crossed every “T,” and dotted every “I.” Still, the “Medicare Development Letters” kept coming. He documented tens of calls to his MAC carrier to inquire about all the delays. He asked all the right questions, and pleaded for their guidance and direction. Then he would wait and wait and wait. Every single time, no matter what he did, no matter how many times he reapplied, or how many times he called, wrote, faxed and yelled, his Medicare applications continued to be “DENIED … pending development.”
“Development of what?,” he cried. He did what they asked, but it was never enough. He made corrections to the applications as they instructed him to, yet it was still never right. He was repeatedly given conflicting information by every “expert” he spoke with. One Medicare Analyst would tell him to do something one way, and yet another Analyst would tell him to do it another way. When it seemed like he should just give-up and give-in to Medicare, a friend referred him to us for assistance.
Time was running out fast because Medicare’s timely filing limit is one year. Any claims submitted for dates of service after that one year mark would deny and it was going to cost this young doctor thousands upon thousands of dollars. He felt certain he was never going to be reimbursed for all of that patient care and work! The long story made short is, that once we evaluated everything, it was clear that “action steps” would be necessary to get this young doctor’s Medicare Enrollment Applications approved, and the $125,000 in pending claims processed and paid.
We went to work fast, gathering all of the facts, data and key information, and knew exactly what had to be done. It took a lot of work, but the end result was HUGE for this doctor. Compliance was in and every one of his $125,000 worth of claims was paid.”
The moral of this story was that it nearly took a mountain to be moved to make the carrier responsible for their role in holding up the enrollment of this doctor. But the mountain WAS moved, and the outcome was favorable. Don’t give up!
Understand the Expectations and Limitations
Every carrier will not have a fee schedule that pays what you believe your value to be, or the value of the care you’re delivering. Insurance participation is a very personal decision, made for a variety of reasons. Agreeing to accept a sub-standard fee schedule may work for you because it serves as a marketing arm for your business. Complete understanding of the difference between what the carrier feels is medically necessary, and therefore payable, and what you think they should pay for, helps manage your expectations. Being available as a participant on a plan may open the door to patients who would not otherwise come see you. This open door allows you to explain chiropractic care, the differences between “medically necessary” and “clinically appropriate” care, and who pays for which, AND allows them to know you and make a decision about you becoming their doctor. Having access to this open door may also come with limitations: lower fee schedules, contractual rules and obligations you don’t like, and other penny ante complications of working with third-party payers. That’s why it’s a personal decision. Do the following to mitigate problems later:
- Read the contract before you sign it! Know if you are agreeing to things against your principles or methodology of treatment. Know if these agreements will affect the processes in your practice.
- Acknowledge that insurance was not meant to pay for everything. Give the patient the simple fact at the beginning of care: “Great news Mrs. Jones! Your carrier will contribute toward your financial responsibility in the office! Isn’t that great!” And know this: No matter how much that contribution is, it’s great. If you own it, your patient will too.
- Have systems and payment plans in place to help make care affordable for your patients when it is their turn to pay. Utilize a Discount Medical Plan Organization (DMPO) like ChiroHealthUSA to offer legal, network-based discounts. Help your patient understand the insurance card is not a Visa or MasterCard!
Know the Medical Review Policy
It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill.
Whether you choose to work with insurance carriers as a participating doctor or not, nearly every service covered by the carrier is likely to have a medical review policy. This policy outlines the expectation of coverage, the types and descriptions of covered diagnoses, and will summarize what the carrier assumes you are doing if you are billing that service or code. For example, a contract with BCBS of Texas states that massage is a covered service. However, if the patient is receiving 97124, Massage Therapy or 97140, Manual Therapy, the doctor may not delegate that to a CA or other provider working under the DC. It is expected that the DC provides the hands-on service. Even though the scope of practice in the state of Texas allows for delegation, the contract signed by the provider supersedes that. What if you are not a participating provider? The rules still apply! They state that the DC must always provide the service to be paid for that muscle work. Be sure you know your medical review policy for any carrier you do business with. These simple steps will help you stay ahead of the game:
- Create a spreadsheet and include a list of every carrier you do business with. Identify whether you are participating or not.
- Pinpoint each major code or code set that you use. Some carriers categorize all physical therapy procedures together, for example, while others list them by individual code.
- Find the medical review policy on each carrier’s website for each code or code set that you use. Note any special rules or particular issues that may apply to the service as you rendered it, such as by delegation. Remedy any outpoints that are identified, and write internal policy to keep from crossing the line.
Bill and Code Correctly
When scouring the Medical Review policy for the most typical services you render, pay close attention to billing and coding guidelines that are particular to that carrier. Although it doesn’t make sense, some carriers follow their own set of rules that are contrary to national coding principles. Some carriers still inexplicably require the “51” modifier on the Extraspinal Manipulation code, 98943. This coding policy is outdated and incorrect, and efforts are underway to get such things updated. Meanwhile, however, whether you agree with the policy or not, if you don’t use a “51’ modifier when billing 98943, you simply won’t be paid. Other rules are easier to follow. It’s easy to stay abreast of correct coding standards by connecting with the American Chiropractic Association or other coding consulting groups. It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill. Keep these tips in mind:
- Update your coding manual annually. Note in your compliance manual every year that you have updated your coding knowledge and applied appropriate changes.
- Make proper coding and billing a “family affair”. Educate and support key team members in learning and staying on top of coding and billing rules and changes. Compliance rules dictate that annual training is documented for all billing and coding personnel and that includes the doctor.
- Know that you DON’T know. You were not anointed a coding or billing Queen or King when you received your Chiropractic Diploma. Keep the skids greased between your office and carriers by aligning with trusted advisors who can assist you with keeping your coding and billing on track and compliant.
Firmly Follow Up
Once you’ve ensured that all the insurance relations tips noted above have been completed, and you’ve billed your appropriate services to a carrier for payment, we want your teeth to come out. Rules and regulations apply to carriers as much as they do providers. When a clean and correct claim is presented for payment, it must be adjudicated within a set number of days. This includes payment OR pending OR denial. Know what your state insurance commissioner has to say about carrier responsibilities for claim processing. Once you know this, set up your internal system of follow up to flag unpaid claims at the appropriate time and get on the phone! Forget tracers! That’s so 1983. Pick up the phone or get online and find out why your bill isn’t paid. And be ruthless until you get your answer. You have every right to fight on your patient’s behalf for payment of your claim. Internal accounts receivable systems that are worked, tracked and managed will ensure that you never miss timely filing deadlines and every cent that is yours will be on its way to your bank account, post haste. Try these tips for a smooth process:
- Set aside dedicated follow up time weekly for unpaid claims from the aging report, and for responding to denials and other reactive items that come in the mail. This often neglected area is usually the culprit in erratic cash flow.
- Pearson's Law states: That which is measured improves and that which is measured and reported improves exponentially. Reimbursement department team members should have metrics that are reported weekly and monthly that include number of outbound calls, dollar amounts of resubmitted claims, and other important data that helps the doctor or practice management see the follow up work being done.
- Be merciless in your pursuit of payment. Go to the supervisor’s supervisor’s boss’s manager if you have to. Use the insurance commissioner. Drag in the employer’s HR department or Ombudsman when you have to. Be an advocate for your patient and be sure you collect what you deserve.
Playing in the insurance sandbox is usually a “win” for chiropractic practices. Whether providing access to more patients who would not otherwise come in if they had to pay out of pocket, or providing a way to be paid what’s reasonable and customary for your services, insurance participation can enhance the business of your practice. You may choose to fully participate in all plans, to selectively identify those with whom you want to interact, or to provide a way for patients to pay you and then be reimbursed. Regardless of your decision, if you decide to work with insurance, do it with your whole heart and soul, and it will be a win-win situation for all parties involved.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at (855) TEAM KMC or