by Mario Fucinari •
DC, CPCO, CPPM •
The world of Medicare can be complex, especially when it intersects with Medicare Advantage plans. Chiropractors often find themselves in a gray area, uncertain about their network status when commercial insurance companies administer Medicare plans through Medicare Advantage. This confusion stems from a fundamental misunderstanding of how Medicare and Medicare Advantage work, particularly concerning network participation and reimbursement.
Understanding Medicare and Medicare Advantage
Medicare, a federal health insurance program, covers individuals aged 65 and older, as well as some younger people with disabilities. Original Medicare includes Part A (hospital insurance) and Part B (in-office limited chiropractic and medical insurance), which covers medically necessary spinal manipulation in chiropractic.
Medicare Advantage (Part C) is an alternative to Original Medicare, offered by private insurance companies approved by Medicare. The Medicare Advantage plan is still considered a Medicare plan because it is health insurance that is subsidized by the federal government. These plans must cover all services that Original Medicare covers but can also offer additional benefits. Medicare Advantage plans often come with network restrictions and different rules for service reimbursement for in-network providers, creating confusion for healthcare providers, including chiropractors.
Chiropractors and Medicare
Chiropractors can never opt out of Medicare, unlike some other healthcare providers. This means they must bill Medicare for services provided to Medicare beneficiaries if those services are covered by Medicare. Specifically, Medicare Part B covers spinal manipulation if it is medically necessary to correct a subluxation (spinal misalignment).
Since chiropractors are required to file active claims to Medicare, either as participating or non-participating providers, they are regulated by Original Medicare. However, when dealing with Medicare Advantage plans, the situation can become more complicated.
Network Status in Medicare Advantage
Commercial insurance companies administering Medicare Advantage plans establish their provider networks. These networks can include or exclude chiropractors based on the company’s policies and the contracts they establish with providers. The Medicare Advantage plans must cover all medically necessary services that Original Medicare covers. However, the Medicare Advantage plans may use their criteria to determine medical necessity for some services.1 Therefore, even though chiropractors are providers in Original Medicare and Advantage plans if they have not signed a contract with that insurance company, they may have different criteria for coverage.
For Medicare Advantage plans:
- In-Network: Chiropractors who have a PPO contract with the Medicare Advantage plan commercial carrier.
- Out-of-Network: Since this is still a Medicare plan, chiropractors without a contract may still be reimbursed for covered services, but may receive lower reimbursement rates, and patients may have higher out-of-pocket costs. They are still required to file a claim for covered services.
Navigating the Confusion
Many chiropractors assume their mandatory participation in Medicare automatically extends to Medicare Advantage plans, but this isn’t the case. On the other hand, some chiropractors assume that since they are out of network with the insurance carrier that is administering the policy, they are exempt from filing the Medicare claim. To clarify, Medicare Advantage plans are still Medicare. If you are an out-of-network provider, you must check the benefits in that plan for out-of-network providers to see if benefits are available. If benefits are available, you cannot opt out of filing the claim, however, it is recommended to check ‘No’ in box 27 of the CMS 1500 claim form, and not accept benefits. In other words, you file the claim, but the patient has only partial coverage. You may be able to back-bill the patient for spinal manipulation up to the Medicare rate for your Jurisdiction and Zone.
With the above facts in mind, chiropractors should:
- Verify Patient Insurance: Unfortunately, patients may not realize what type of Medicare plan they may have. Collect and scan both sides of all the patient’s health insurance cards, front and back.
- Check Benefits: Verify the patient benefits and double-check the explanation of benefits to confirm the coverage.
- Understand Plan Rules: Familiarize yourself with the specific rules and reimbursement policies of the Medicare Advantage plans you may be in network with.
- Communicate with Patients: Clearly inform patients about their network status with their specific Medicare Advantage plan and explain that there is no guarantee of coverage. Manage expectations regarding coverage and out-of-pocket costs. If no benefits are available, I recommend that the patient sign a Good Faith Estimate since the use of the ABN form in Medicare is expressly prohibited. Consider legal discount plans such as ChiroHealthUSA to avoid allegations of inducement or kickbacks.
- Billing Practices: Ensure your billing practices align with the requirements of the Medicare Advantage plan, as these can differ from Original Medicare.
Conclusion
While chiropractors cannot opt out of Original Medicare, their status in Medicare Advantage plans depends on their contractual relationships with these plans. This distinction is crucial to avoid confusion and ensure proper reimbursement. By understanding the nuances of Medicare Advantage and maintaining open communication with patients and insurance providers, chiropractors can navigate this complex landscape more effectively, ensuring they remain compliant while providing necessary care to their patients.
Dr. Fucinari is a frequent lecturer for ChiroHealthUSA, NCMIC, and Foot Levelers. Dr. Fucinari is a Medicare and Compliance national speaker. He is a Certified Professional Medical Compliance Specialist and has served on the Carrier Advisory Committee for Medicare for the last 15 years. The required OIG Compliance Manual for Medicare, HIPAA Manual, and ICD-10 Coding books are available at www.Askmario.com. To have Dr. Fucinari speak at your continuing education events, please contact Dr. Fucinari at Doc@Askmario.com.
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