Misinformation regarding chiropractic services and Medicare
Published: 2009-05-14 09:13:55
Author: American Chiropractic Association | Chiropractic Economics | April 15, 2009
April 15, 2009 — The following information was extracted from a Medicare Learning Network (MLN) Matters publication. This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to correct misinformation in the chiropractic community relating to Medicare and its regulations as they relate to chiropractic services. This article is informational only and represents no changes to existing Medicare policy.
Misinformation #1: There is a 12 visit cap or limit for chiropractic services.
Correction: There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5. (This manual is available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS Web site.)
There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.
The Social Security Act (Section 1862 (a) (1); see http://www.ssa.gov/OP_Home/ssact/title18/1862.htm on the Internet) provides that Medicare will only pay for items or services it determines to be "reasonable and necessary," and if those items or services can be shown to be “reasonable and necessary,” then those items or services are covered and will be paid by Medicare.
Misinformation #2: If you are a nonparticipating (nonpar) provider, you do not have to worry about billing Medicare.
Correction: Being nonpar does not mean you don’t have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties.
A nonpar provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The nonpar provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.
It is important to note that nonpar providers may choose to accept assignment, therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.
Whether or not a nonpar provider chooses to accept assignment on all claims or on a claim-by-claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.
You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf on the CMS Web site. The form contains important information regarding the participation process and the annual opportunity you have to make or change your participation decision.
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Published: 2009-05-14 09:13:55
Author: American Chiropractic Association | Chiropractic Economics | April 15, 2009
April 15, 2009 — The following information was extracted from a Medicare Learning Network (MLN) Matters publication. This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to correct misinformation in the chiropractic community relating to Medicare and its regulations as they relate to chiropractic services. This article is informational only and represents no changes to existing Medicare policy.
Misinformation #1: There is a 12 visit cap or limit for chiropractic services.
Correction: There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5. (This manual is available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS Web site.)
There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.
The Social Security Act (Section 1862 (a) (1); see http://www.ssa.gov/OP_Home/ssact/title18/1862.htm on the Internet) provides that Medicare will only pay for items or services it determines to be "reasonable and necessary," and if those items or services can be shown to be “reasonable and necessary,” then those items or services are covered and will be paid by Medicare.
Misinformation #2: If you are a nonparticipating (nonpar) provider, you do not have to worry about billing Medicare.
Correction: Being nonpar does not mean you don’t have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties.
A nonpar provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The nonpar provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.
It is important to note that nonpar providers may choose to accept assignment, therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.
Whether or not a nonpar provider chooses to accept assignment on all claims or on a claim-by-claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.
You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf on the CMS Web site. The form contains important information regarding the participation process and the annual opportunity you have to make or change your participation decision.
Full story