A Dash of Persistence with a Touch of Honey: A Winning Combination

:dropcap_open:M:dropcap_close: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:

 

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!

 

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:

 :dropcap_open:It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill.:quoteleft_close:

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: 

 

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:

 

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:

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.