We Need to Stop Playing by Medicare's Rules
Editor's note: The following letters to the editor all address Dr. David Seaman, et al.'s recent article on Medicare documentation: "The Medicare Hurdle That Continues to Block Our Professional Progress" (April 9, 2012 issue).
In the above-referenced article, Medicare is the problem. It never wanted chiropractic inclusion, so it's defined what we do using its own criteria. Medicare has no interest in chiropractic, even if we do save the system money.
If we truly fight Medicare, it should be in our mode of wellness care. The AMA, on its Web site, is urging doctors to perform "wellness visits" versus routine office visits, as Medicare guidelines will reimburse MDs $160 for an initial wellness visit and $115 for quarterly follow-up wellness visits, versus a $70 routine office visit.
There has always been discrimination against chiropractic in Medicare, which does not pay for what we do: maintain the patient's ability to self-regulate and heal as nature intended without drugs or surgery. Historically our profession has never been about treatment of pain, but addressing dis-ease in the body and restore tone. Our profession has always stated that all dis-ease (subluxations) is caused by traumas, toxins, thoughts (auto-suggestion) and stress to the body. The AMA in 2009 stated that over 90 percent of all disease seemed to stem from emotionally induced illness, aka stress. It only took medicine 114 years to catch up with D.D. Palmer.
Medicare acts as though we are a subspecialty of medicine, not a separate and distinct science, art and philosophy profession. We do not need to change what we do to satisfy Medicare and its biased system. We need to break the ties and quit playing by Medicare's rules.
Gary Brettmann, DC
President, Chiropractic Society of Texas
Medicare Requirements Are Over-the-Top and Unrealistic
It seems incredible to me, after being in practice for 27 years, that Medicare is setting such demanding chiropractic documentation requirements. Ninety percent of what they are now demanding we do, they don't even reimburse us for! How can that be? What other practitioner performs all of these tasks and requirements without adequate payment? It certainly seems over the top in terms of realistic expectations and performance.
Jeanne M. Sharpe, DC
Refuse to Play the Game Only One Way
I read with anticipation the article in the April 9, 2012 issue, "The Medicare Hurdle That Continues to Block Our Professional Progress." The assumption here, as in many other articles on this topic, is that chiropractors are woefully inadequate record-keepers who do not deserve to be reimbursed for patient care until we become more proficient reporters. I keep wondering why no one is asking the question: "Why is Medicare using arbitrary documentation requirements that are extremely detailed and difficult, if not impossible, to meet?"
Yes, professionally we do need to accept higher minimum standards of chiropractic documentation; however, we are not all doing as badly as we are being led to believe. New York hospital record reviews in 2010, for code 99205, had a 5 percent acceptance rate. With Medicare, record reviews are largely a no-win scenario for all the professions.
Knowing the Medicare documentation requirements for your MAC region is imperative, as is continually improving your record-keeping. However, I still have little faith that even the best records are consistently reimbursed. I would love to know if the authors of the article are consistently getting reviewed and paid by following the documentation algorithm they presented.
Documentation is not the Medicare hurdle that is blocking our professional progress; it is just the smokescreen. The Medicare hurdle that is blocking our progress is the limited number of covered chiropractic services under Medicare, including the definition of maintenance care and the fact that only a limited, obsessively documented episode of acute care is a covered service.
The amount of information required to substantiate acute care is out of balance with the reimbursement structure. How did we get to the place where extensive data is required to substantiate medical necessity for one code reimbursed at less than $30, when most of the services required to obtain that extensive data (history and exam, re-exams, diagnostic testing) are non-covered?
If covered services were expanded beyond their limited parameter of acute care, the need for obsessively detailed records could relax to a reasonable level. This, of course, is assuming that the conspiracy to deny chiropractic claims at all costs, as payback for the Wilk case, is not true.
Our present reality is that pre-payment reviews of 989xx codes, in N.Y. at least, have just begun and we have a long way to go before it is over. Interestingly the timing of chiropractic pre-payment reviews coincides with the electronic health records incentive payments for qualified Medicare payments to providers. At this rate, many N.Y. chiropractors will lack qualified Medicare payments even if they do have qualified electronic health records!
The loss of Medicare revenue in many N.Y. practices, due to 100 percent denial of all Medicare claims with no end in sight, is certainly a hurdle that is blocking professional progress! It is time for the profession to take a stand for our patients and our practices by politely refusing to play the game only one way.
Chiropractic services cost less than 2 tenths of one percent of the total Medicare budget, yet Medicare MACs are spending significant taxpayer resources to review and deny chiropractic services. Recouping 100 percent of the Medicare chiropractic benefit wouldn't make a dent in the Medicare budget woes.
What can we do? My office and some of my colleagues have been considering (and acting on) the following:
Don't bill Medicare at all. Patients seeking care check Option 2 on the ABN. This results in no Medicare billing and the patient paying cash for the care. Patients are charged the Medicare fee schedule for 989xx codes and regular fees for any non-covered services rendered.
An alternative is having the patient check Option 1 on the ABN, billing the 989xx CPT code with the -GA modifier. This results in the office visit being billed as maintenance care and the Medicare Summary Notice coming back to the patient showing the care was a non-covered service that they are responsible for. This option is best for patients with secondary insurance that is not a Medicare supplement.
Explain to patients that Medicare has a very limited definition of what represents a chiropractic covered benefit. Patients with chronic spinal degeneration have no reimbursement allowance for supportive and maintenance chiropractic care under their present Medicare contract.
Even though Medicare is not presently reimbursing for care, because the doctor is credentialed with Medicare, the patient is protected by the Medicare fee schedule for the 989xx codes, which will save them money.
Invite patients to contact their federal legislators to change the Medicare benefit so all levels of care (acute, chronic, supportive and maintenance) are covered; 60 chiropractic visits per year with no medical necessity requirement is a start.
Continue the push for Medicare to look at data showing the high patient satisfaction and cost-effectiveness of chiropractic services, especially when they result in being lower-cost substitute care for other more invasive and expensive (medical) treatments with less evidence-based support. Contact AARP, senior groups and local federal legislators to discuss the issues.
Join your state and national chiropractic organizations, and be active with an association committee or two once you join.
The present Medicare rules are designed to make it very difficult for the chiropractor to get paid if a claim is reviewed. Many areas of the country have not started experiencing pre-payment reviews. All is business as usual there; you bill and the claim gets paid without records ever being reviewed. In our region, even doctors with bulletproof electronic health records, with all the fields completely filled in, have quickly realized they are not exempt from having all their claims denied. Once Medicare reviews began in N.Y, reimbursements largely stopped. Running a practice when a whole population of patients' cash flow abruptly stops is a huge challenge.
Post-payment audits are coming after that, we are told. These will recoup payments made on older claims deemed not supported for payment once reviewed. Recoupment will come straight out of the checking or savings account we each have to register with Medicare through PECOS, allowing them to both electronically deposit and withdraw funds.
Non-participating status is an option worth considering for the long haul. With non-par status the patient pays the office, the office bills Medicare and Medicare reimburses the patient directly, if reimbursement is authorized. Switching to non-par status is only available for 1-2 months at the end of each calendar year.
The bigger challenge is globally recovering from Medicare's upside-down approach to fixing the problem: denying care and payments without analyzing the massive savings and benefits to the Medicare system if they would encourage, rather than interrupt effective, lower-cost chiropractic care.
Refusing to play the game only one way, while still following the rules, is a step in the right direction, but it takes courage and determination. Continuing to bill Medicare and presenting required documentation for pre-payment reviews may get your claims paid. But if payments start being routinely denied and your only recourse is to plow through three levels of appeals or give up, there is a third option. Can you get there (to a cash Medicare practice) from here; caring for your Medicare patients, getting paid (by the patients) and following Medicare's requirements by having the patients sign an ABN, acknowledging their willingness to pay out of pocket for care? Yes, you can; one Medicare patient at a time.
Carrie Goettsch, DC
We Can Offer a Better Option
What a sad realization that we, as a profession, bow down and cut our own throats in the name of Medicare acceptance. The authors of the Medicare article did a fine job teaching the reader the requirements of Medicare. But why do we accept this? Shame on our chiropractic leaders years ago who let it be so. Shame on us now for not fighting for change.
Medicare's awful description is not subluxation reduction. It is temporary patchwork. I can get the same results with a shot of vodka. We've trained a population to seek chiropractic only when the tab is paid by someone else.
To make matters worse, the demanded documentation is worthless. There is nothing more boring than chiropractic notes describing a sore joint. Our notes should be documenting the miracles that happen when a sleeping nervous system is unlocked from its self- induced physiological prison.
I should be thankful my seniors come in for drug-free health-building, but they never experience true health-building. They get a few cracks on the spine that barely relieve the true nature of their nervous-system dysfunction. I don't even treat my spine that way.
Yet in the same issue as the Medicare article, we see a grand story about "Dr. Phil." He gets adjusted twice a week because consistency counts when it comes to receiving adjustments to combat a stressful world. We need to teach our older population the truth about their own healing and offer them a better option than Medicare.
Lisa Ann Homic, MEd, DC