by Mario Fucinari •
DC, CPCO, CPPM •
In the complex landscape of healthcare reimbursement, the intersection of Medicare Advantage and chiropractic services has become a focal point of confusion for both providers and patients alike. Chiropractors, unlike certain other healthcare providers, cannot opt out of Medicare. (MedLearn Matters SE0479). They may limit the number of Medicare patients in their practice, but they may not choose to be enrolled in Medicare when treating Medicare patients. This fact results in confusion when accepting Medicare Advantage patients. Is the Medicare Advantage plan Medicare, or is it a commercial PPO plan? The answer to that question yields confusion, which may lead to fines, errant office policies, and challenges to the financial viability of a practice.
Medicare Advantage plans, also known as Medicare Part C, are offered by Medicare-approved private companies that must follow rules set by Medicare. These plans provide an alternative to Original Medicare (Parts A and B) by bundling hospital and medical coverage into a single plan, often with additional benefits such as vision, dental, and prescription drug coverage. This arrangement can lead to confusion because the benefits and coverage options under Medicare Advantage may differ from those under Original Medicare.
A growing number of chiropractors have become disillusioned with the dwindling reimbursement of insurance coverage, per diem caps, limitations on care, and recoupments. The chiropractors may have chosen to adopt a cash-only practice or, with the addition of Medicare patients, a hybrid type of practice. Meanwhile, the competition between commercial carriers for Medicare Advantage patients is quite evident with the annual barrage of advertisements luring patients into joining Medicare Advantage plans. To influence the patient’s selection of a carrier, the companies will offer additional benefits such as health club memberships, vision care, and dental care. In 2022, the U.S. Senate Committee on Finance published a report indicating that up to 35% of Medicare beneficiaries may be victims of misleading marketing tactics by these companies.1 Reality settles in when the patient comes to the chiropractic office. They may have limited coverage, no coverage, or be required to see an in-network provider of the Medicare Advantage plan administrator.
The chiropractor and staff are confused because while the patient has a commercial Medicare insurance plan, the contract is unique for each patient. The patient may have in-network and out-of-network limitations yet still be considered a Medicare plan, resulting in the chiropractor being locked into filing claims with a carrier they purposely chose not to be in network with. The Medicare requirements for chiropractors may cause the chiropractor to be obliged to file claims for Medicare patients, including those enrolled in Medicare Advantage plans.
Adding to the confusion, CMS has stated that Medicare Advantage plans must offer reimbursement for services that Part B Medicare offers.2 However, the reimbursement rate may differ between the carriers. Medicare Advantage plans may have different coverage rules, copayments, and referral requirements compared to Original Medicare. This variability complicates the process of determining patient benefits and filing claims for chiropractic services. If the chiropractor is not in network with this carrier, the carrier may have to offer reimbursement for spinal manipulation, but patient access and reimbursement may be challenged with restrictions. Unfortunately, patients typically assume their benefits align with those under Original Medicare, causing them to become angry with the chiropractor and staff, not realizing that we are not responsible for the insurance plan the patient chose.
Solutions
The solution to this problem may be daunting and result in increased work for the chiropractic staff and the patients alike. One may impulsively want to not accept Medicare patients, but the financial ramifications may be significant when the solution may not be difficult. First, do your due diligence to check benefits and decide if you are going to accept the patient before the patient comes to the office for their consultation. If you are an out-of-network provider with the administrator of the Medicare Advantage plan, you must specify when checking benefits that you are an out-of-network provider. I recommend asking the following questions:
- Does the plan follow the Medicare fee schedule for out-of-network providers?
- Is spinal manipulation covered at the Medicare rate for out-of-network providers?
- Are any other services reimbursable under the plan for out-of-network providers?
- Does the plan accept the AT modifier?
Medicare Advantage plans are “expressly prohibited” from using the Advanced Beneficiary Notice of Non-Coverage (ABN) form.3 Therefore, I recommend a Good Faith Estimate (GFE) form for any services that the patient will have to pay out of pocket. However, the GFE is only used if the patient is not covered under any managed care program and has to pay out of pocket. For the patient paying out-of-pocket or chooses not to use their insurance, If the office utilizes the services of a Discount Medical Plan Organization such as ChiroHealthUSA, then the need for the GFE is eliminated and the patient will enjoy the benefits of a legally discounted plan. Ethically, helping patients with the cost of care is the right thing to do. It is a win-win proposition.
Addressing these challenges requires improved communication and education among chiropractors, patients, and Medicare Advantage plans. Chiropractors need clear guidance on their obligations and options when treating Medicare Advantage patients, while patients require transparent information about their coverage and out-of-pocket costs.
In conclusion, while Medicare Advantage offers expanded benefits and choices for patients, it also introduces complexities that can be challenging for chiropractors and patients alike. Clear communication, education, and policy reforms are essential to navigating these complexities and ensuring that chiropractic care remains accessible and viable within the Medicare Advantage framework.
- Deceptive Marketing Practices Flourish in Medicare Advantage, page 10.
- Understanding Medicare Advantage Plans. Page 7.
- Advance Beneficiary Notice of Noncoverage (ABN) documents aren’t valid for Aetna® Medicare Advantage members.
Dr. Mario Fucinari is a Certified Professional Compliance Officer, Certified Physician Practice Manager, Certified Insurance Consultant, and a Medicare Carrier Advisory Committee member. He is the author of several HIPAA and compliance-related manuals. As a ChiroHealthUSA Speaker’s Bureau member, he travels throughout the year, speaking to audiences nationwide and sharing his chiropractic expertise and insights about documentation, billing, and coding issues. If you wish to have Dr. Fucinari as a speaker for your organization, contact ChiroHealthUSA. Questions can be sent directly to Dr. Fucinari at www.AskMario.com or by email at doc@askmario.com.
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Why is the Discount Challenge prize amount $15,024? Because that is the average “per-occurrence” fine for Medicare inducements. That’s not $15,024 per patient, that’s not per provider, that’s PER VISIT. Stinks, doesn’t it? To us, the prize amount is worth the investment if we can help our profession better understand proper discounting.