Just When You Thought They Couldn’t Go Lower
Hello Doctors, Therapists and Staff,
The following is my review, comments and action steps regarding two abruptly launched directives by United Healthcare[UHC]/Optum and Humana. Make no mistake, this is no unplanned error on their part and smells of future onerous rollouts, but I’ll get to that shortly.
In my last e-newsletter I offered an update of the UHC-owned Change Healthcare ransomware cyber-attack and the difficulties a large percentage of the nation’s providers, including hospitals, were having with financial resources drying up. I won’t go into the un-truths and empty promises spewed by UHC CEO Andrew Witty to Congress this past May, but let’s just chalk these two sudden changes to a UHC/Optum departure from that testimony.
The first directive on this hit parade involves a real attack on the validity of a signed Assignment of Benefits, as well as the rights of providers to seek insurance reimbursement. UHC is denying provider appeals for non-payment unless the patient/policyholder has given their authorization, in writing, specifically what is called an “Appointment of Representative”. This draconian act shows why a solidly written Assignment of Benefits form is so critical when fighting back against such insurer tactics. Centers for Medicare and Medicaid [CMS] actually have a form they created [Form CMS-1696] named Appointment of Representative for Medicare-related cases. You can add a derivation of this form to the stack of forms you already have patients fill out and sign, or at the least you can add the following wording to your existing Assignment of Benefits that I gleaned from the CMS form [this in no way guarantees clear sailing should an appeal be necessary, but unless you already utilize an Appointment of Representative it’s better than not including it!]:
“Appointment of Representative: I appoint the provider or provider office named in this form to act as my representative in connection with my claim(s). I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated.”
Upon receiving denials of appeals received from UHC/Optum be careful to read the remark/denial codes used. Although at the time of this writing we’re not sure of the codes they will be using it could be a denial based on no proof of appointment of representative. In such a scenario, you will have to appeal once more, but with a properly executed Assignment of Benefits containing the appropriate Appointment of Representative verbiage. By instituting this in your Assignment of Benefits, should you need to appeal a claim you can include your updated Assignment of Benefits, and be sure to make reference that the Appointment of Representative is contained therein. Read, inspect! If you’re not sure of the reason for the denial of your appeal feel free to send to me and I’ll be happy (well, modestly enthused) to review for you – just be sure to thoroughly sanitize the denial so no patient name or identifying information can be seen.
SideNote***: Watch for a future newsletter of another critical addition to your Assignment of Benefits. This may be the most important addition of anything you could ever include in the AOB, and may be the sole means of fighting improper denials and appeals denials. Watch for it!
The second directive to come out was the sudden announcement from UHC/Optum and Humana that Pre-Authorizations would be required for their Medicare Advantage plans for certain healthcare providers, services, and regions. The Humana requirement will begin August 29th, and the UHC/Optum requirement will begin September 1st. I’m going to address Humana and UHC/Optum separately, but I first want to make a couple things clear.
The first has to do with your documentation – review it! Improve it! Whether or not you get the authorization to treat may well be dependent on the validity and completeness of your documentation. I expect an unusual, if not irrational, amount of denials for treatment authorizations, and the reviewer will pin the “nay” decision on insufficient evidence in documentation for your care to be necessary. Don’t make it easy for them to do so. If you can’t be objective in reviewing your notes ask someone smarter than you that you trust, and who can be brutally honest to say whether your notes are worthy of an Academy Award, or not even good enough to line the cat litter box.
The second has to do with diagnosis codes you assign. Remember to always code to the highest level of specificity! If your examination reveals a possible neurological component then code it with a neurological diagnosis code as the primary! Functional and structural diagnosis codes lay somewhere in the middle, and leave the generic pain and spasm as the last to mention, if present. You should be coding like this in all situations, but just in case it’s slipped your consciousness snap out of it!
UHC/Optum Medicare Advantage plans will be the first insurer we’ll tackle as they are the larger of the two and have more of a widespread effect to providers. You must submit the pre-authorization or Patient Summary Form (PSF) request through the UHC online portal after you perform your initial evaluation and before you can get authorization to begin treatments, so be sure you are signed up to do so at www.uhcprovider.com. The healthcare fields requiring a pre-authorization include multidisciplinary offices, outpatient hospital settings, physical therapy, occupational therapy, speech therapy, and chiropractic services that would be billed with the -AT modifier. If you received notification of this new process then you are definitely in an office or region affected. For all the details of what is entailed in properly completing the UHC/Optum Medicare Advantage pre-authorization process I have included the direct UHC webpage at the end of this newsletter following some final comments.
Humana is the other insurer that has enacted a pre-authorization process, and rather ominously the webpage references Humana Medicare Advantage AND commercial non-PPO patients as the targets of the pre-authorization requirement. With this insurer, the responsibility of receiving, processing and approving the pre-authorization requests is not with them, but with a third-party utilization management company, WholeHealth Networks (WHN). Here, too, you must enroll at WHN’s web portal, www.wholehealthpro.com, in order to submit your pre-authorization request. The healthcare fields and services involved are many, but in particular to the recipients of this newsletter chalk chiropractors, physical therapists, and occupational therapists among the affected. Here, too, I’ll put the direct Humana webpage at the end of this newsletter after my final comments. Make sure all providers and staff review these pages together so you can discuss, and I would suggest printing these pages and maintain them in a protective binder so they can be easily referenced, if needed.
It’s ironic that both these major insurers would roll out pre-authorization requirements almost simultaneously. What is even more ironic is that this is happening at a time when Congress, the White House, and Medicare are all trying to force Medicare replacement plans to cut down on pre-authorization requests and the delays it causes in rendering care to patients in immediate need. These insurers are not just thumbing their nose at the government’s request, but are perhaps hopeful that pro-insurance judges will block such government attempts. They are also hopeful that an anemic or non-existent response from providers and policyholders will be seen as a “no harm – no foul” show to both the courts and Congress. It’s all of our duty to let them know otherwise! We must implore our patients to call UHC/Optum [855-586-3843] and Humana [800-758-5002] and tell them to stop blocking or holding up access to care they need; and then call our state and federal legislators and ask them why they are allowing these insurers to institute onerous pre-authorization protocols when Congress is in the process of trying to get insurers to do just the opposite. If you would like a printable flyer that you can hand out to your UHC/Optum and Humana Medicare patients email me and I’ll send as an attachment.
There are other theories as to why these insurers are enacting these protocols at this time. Some feel this is their way, especially by UHC/Optum, of recouping millions of dollars in losses suffered by the UHC-owned Change Healthcare debacle several months ago. Many providers and hospitals still haven’t been made right financially, and between potential fines and having to pay late interest to providers UHC is trying anything they can to limit their financial losses. Other theories, which I am very leery and suspicious of is that this is a test before launching similar requirements for their other insurance plans. You test the temperature of the water by rolling out your plan to a smaller market to see what the reactions will be. When temperatures cool, or there is little to no repercussion you widen the rollout to include other plans, larger geographic areas, etc. It’s a sinister method that been done successfully many times before.
It’s crucial that we not be complacent and roll over when such challenges fall to us. We must be diligent in pushing back, and it’s just as important that we educate and encourage our patients to do the same as they are paying for better treatment than this by their own insurance company. Make the calls, you and staff; dial the number and hand the phone to patients when they come in. With enough complaining, persistence and fortitude just like Jericho we might be able to bring these walls tumbling down!
UHC/Optum Pre-Auth Webpage
Humana Pre-Auth Webpage
https://provider.humana.com/coverage-claims/prior-authorization
Think you might require billing and collection services? Call us for a no obligation chat to discuss your needs, or any difficulties you may be experiencing with your insurance revenue management. We work and bill directly from your software, and our knowledge and experience in different software programs now exceeds more than a dozen programs! We also post your payments for you directly in your software! Mention you read this e-newsletter and we’ll waive your start-up fee!
***We are pleased to announce the EHR software we work with has expanded and now includes the following: ChiroTouch, ACOM, PayDC, EZNotes, Eclipse, ChiroHD, Office Ally, ChiroFusion, zHealth, EmpowerEMR, CollaborateMD, MediSoft, Jane App, and more! Don’t see yours on the list? We continue to expand every month! Call to find out more!
Yours in health and wealth,
Dr Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
Update on Change Healthcare Cyberattack,
and eviCore-CAC-Avmed Claims
Hello Doctors, Therapists and Staff,
The following is my update of the Change Healthcare ransomware cyberattack based on the latest information I’ve been able to glean from several official health news outlets. I’ve tried to present this information as best as understandable. Please note that some of this might not seem like it pertains to you, but understand several things: First, this cyberattack has had ripple effects that created damage and havoc in the most unlikely way; second, although you might use a clearinghouse other than Change, many clearinghouses have to forward certain claims through Change to get to the proper insurer – as Change is owned by UHC certain UHC-owned insurers mandated claims process via Change [it’s good to be king]; third, different specialties were affected in different ways; and fourth, where one might think temporary financial aid is available to them you must read the “rules” closely.
At the end of my update I’ll also address the current status of CAC, AvMed and eviCore as it relates to Chiropractic claims at the least. For our current clients we have also attached a document from eviCore speaking on the Change Healthcare matter and its effect on CAC and AvMed claims and where claims should be addressed at this time. Of course, this could change once this madness is behind us. Here is my synopsis:
As the aftermath of the cyberattack on Change Healthcare, a subsidiary of UnitedHealth Group, continues to impact healthcare operations nationwide, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) are actively working to mitigate disruptions and support affected providers and suppliers.
CMS Actions and Support: CMS recognizes the significant challenges faced by healthcare providers and suppliers due to disruptions in claims processing and payments resulting from the cyberattack. In response, CMS has taken several proactive steps to offer assistance and ensure continuity of operations:
1. Communication and Coordination: CMS is in regular communication with UnitedHealth Group and Change Healthcare/Optum, urging them to promptly communicate with the healthcare sector and provide viable options for interim payments to affected providers and suppliers.
2. Financial Assistance Programs: On March 9, 2024, CMS introduced the Change Healthcare/Optum Payment Disruption (CHOPD) accelerated payments for Part A providers and advance payments for Part B suppliers [my italics] experiencing claims disruptions. These payments, equivalent to up to thirty days of claims payments, aim to alleviate cash flow problems caused by the Incident. Repayment will occur through automatic recoupment from Medicare claims over a 90-day period.
3. Encouragement to Payers: CMS is actively engaging with private health care plans, encouraging them to support efforts to minimize further disruptions to the healthcare sector. Additionally, CMS has urged Medicare Advantage (MA) organizations to offer advance funding to providers most affected by the cyberattack. Unfortunately, my research hasn’t found any of our specialty groups being given any special consideration.
Eligibility and Certification Requirements: Providers and suppliers seeking CHOPD accelerated or advance payments must meet specific eligibility criteria and make the following certifications:
- Eligible providers/suppliers are those experiencing disruption in claims payment or submission directly related to Change Healthcare’s platform.
- Certifications include the inability to submit claims to Medicare, lack of alternative funding sources to cover the disruption, and assurance of ongoing business operations.
- Providers/suppliers must acknowledge terms of the payment, including repayment obligations and recoupment procedures.
Next Steps for Providers: To navigate the current challenges effectively, providers and suppliers are advised to:
1. Stay Informed: Continuously monitor updates from CMS and other payers regarding payment options and support programs.
2. Collaborate with Payers: Maintain open communication with all payers to access timely payments and explore additional short-term funding opportunities.
3. Assess Insurance Coverage: Consult liability insurers to determine coverage for disruptions caused by the cyberattack.
Conclusion: During this challenging time it is important for all healthcare providers to keep in contact with their clearinghouses, and specifically ask if they have been affected by the Change Healthcare situation. If so, what steps are they taking to work around the inability to transmit through Change Healthcare’s system. Our team at iCollect is also attempting to gather information from the many clearinghouses we work with, including alternate means to transmit claims, if possible. In addition, it’s important that you forward to us any communications you receive from your clearinghouse regarding this, or any other situation. You will most likely get such notifications before we will so be sure to forward any such news to us right away! By working together and staying informed, we can navigate through these challenges and emerge stronger than before.
Now, for those of you lucky enough to be CAC AvMed providers I have attached an announcement that was sent out by eviCore this month following the Change Healthcare cyberattack. In the announcement they not only provide what address AvMed claims should be sent to, but they give a payerID# for electronic billing as well. When you’re staff creates a “new” insurance in your software you might want to name it eviCore-AvMed, so they choose the right insurance for those cases. Keep in mind, when this Change Healthcare issue is behind us [not close yet], eviCore could change things again!
We found when calling eviCore, they have yet to begin processing February claims because of the Change Healthcare matter. On top of that, because of the volume of calls they’re getting they are making providers ask for status, and in some cases appeals, by email only. Our collection crew has been creating spreadsheets to keep track of all that is outstanding.
So, generally this seems to be part of the Change Healthcare debacle. We’re keeping our fingers crossed that this will resolve soon although none of my health news feeds have reported any advancement so far on that front.
Think you might require billing and collection services? Call us for a no obligation chat to discuss your needs, or any difficulties you may be experiencing with your insurance revenue management. We work and bill directly from your software, and our knowledge and experience in different software programs now exceeds more than a dozen programs! We also post your payments for you directly in your software! Mention you read this e-newsletter and we’ll waive your start-up fee!
***We are pleased to announce the EHR software we work with has expanded and now includes the following: ChiroTouch, ACOM, PayDC, EZNotes, Eclipse, ChiroHD, Office Ally, ChiroFusion, zHealth, CollaborateMD, MediSoft, Jane App, and more! Don’t see yours on the list? We continue to expand every month! Call to find out more!
Yours in health and wealth,
Dr Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
Warning to Healthcare Providers: Change Healthcare Cyberattack Sparks Cash Flow Crisis
Greetings Doctors, Therapists & Staff,
I hope by now that you are aware of the ransomware attack that Change Healthcare experienced last month. I’ve been monitoring the dozen, or so, healthcare news feeds I follow to keep track of the massive damage caused by this cyberattack, as well as any impending fixes on the horizon of which there hasn’t been much shared on that front. If you haven’t kept up with this story I’ll provide a brief recap.
In the wake of the February 2024 Blackcat ransomware attack on UnitedHealth Group-owned [UHC] Change Healthcare, the Department of Health and Human Services (HHS) has issued a stern warning to healthcare providers nationwide. The cyberattack, which incapacitated over 100 of Change Healthcare’s systems, has sent shockwaves through the industry, leaving providers scrambling to cope with severe cash flow problems.
Providers relying on Change Healthcare’s systems for crucial tasks like insurance coverage verification, claims submission, and payment processing have found themselves in dire straits. The fallout has prompted several industry groups to petition the HHS for assistance, citing the crippling impact on their members’ financial stability. According to recent statistics 94% of hospitals are experiencing a financial impact, and healthcare providers, in general, may be losing up to $100 million a day from the cyberattack.
UnitedHealth Group’s temporary financial assistance program has drawn criticism for its limited eligibility criteria and burdensome terms, exacerbating frustrations among affected providers. The HHS, while acknowledging the gravity of the situation, has emphasized the need for concerted efforts to minimize disruptions to patient care.
In response to mounting pressure, the HHS has rolled out a series of flexibilities aimed at alleviating the strain on healthcare providers. These measures include expedited processes for changing clearinghouses, relaxation of prior authorization requirements, and encouragement for payers to offer advance funding to affected providers.
Providers grappling with claims processing challenges are urged to reach out to their Medicare Administrative Contractor (MAC) for support. The CMS has instructed MACs to fast-track new electronic data interchange (EDI) enrollments and accept paper submissions if necessary.
Despite these efforts, concerns linger that the new flexibilities may fall short of addressing the full extent of providers’ financial woes.
The cyberattack on Change Healthcare serves as a stark reminder of the critical need to bolster cybersecurity resilience across the healthcare ecosystem. The HHS has reaffirmed its commitment to enhancing cybersecurity measures, urging stakeholders to prioritize cybersecurity with renewed urgency.
Providers are advised to stay vigilant and proactive in safeguarding patient data and financial stability. It is imperative that providers check with their clearinghouses to ascertain how they are addressing the aftermath of the cyberattack and safeguarding patients’ protected health information (PHI).
As the healthcare industry navigates the fallout from this cyberattack, the resilience and collaboration of providers, industry stakeholders, and government agencies will be crucial in mitigating the impact and ensuring the continuity of care for patients nationwide.
All that said, a couple more notes of importance here. For our clients, we continue to monitor for any denials via electronic submissions that are directly related to this cyberattack. Please be aware that many clearinghouses must funnel claims through Change Healthcare to reach the desired insurance carrier. This is one of the reasons why so many entities were against UHC being able to purchase Change Healthcare. It has created a near monopoly of sorts as UHC owns so many insurance entities [ie Optum, UMR, etc], or have very “interesting” ties to other insurers where deals are made that require e-claims to arrive via Change Healthcare. So, your clearinghouse may have to funnel certain claims to another clearinghouse [Change Healthcare] before it finds itself at the final insurer destination. These ties have potentially compromised those clearinghouses unrelated to Change Healthcare because of the cyberattack threat.
If you have recently noticed batches of e-claims denied, since February or early March, for reasons you’ve never experienced before it’s a good bet the Change Healthcare incident is behind it. In some cases we’ve been able to re-route the claims if our clients’ clearinghouse has already effected such a fix; in other cases, we may have to switch these e-claims to printed claims and mail them in. It’s a tedious and costly process as some insurance companies have continued to refuse paper claims regardless of the Change Healthcare matter, and even with HHS flashing warnings to insurers to allow for all methods of claims submissions until this is resolved. We also continue to get mixed messages from insurance companies when we call as sometimes we hear “go ahead and mail”, and sometimes we hear “don’t mail, they’ll just be trashed; give it time for the original problem to be fixed” – all this from the same insurance company!
We understand the financial stress this puts to all providers, but know we’re on it and will do what we can to get claims submitted as soon as possible. Know, too, we cannot repeatedly resubmit electronically through the same clearinghouse until the all-clear is issued. The claims will just continue to get denied or kicked out not to mention really anger the clearinghouse.
One critical proactive measure that each and every provider should take immediately is to place a call to your respective clearinghouse and ask them how they are affected by the Change Healthcare cyberattack; what are they doing to safeguard themselves and protect your patients’ PHI information; how can you get any of your denied e-claims submitted safely to the insurance carriers [have they developed a work-around]; when do they expect to be back at full e-claim submission capacity?
I hope this has helped to shed a little more light on what has been happening in the claims submission world due to this cyberattack, and how your claims may be affected now and in the near future. Use this opportunity as well to check on your own malware programs in your office and home systems.
Think you might require billing and collection services? Call us for a no obligation chat to discuss your needs, or any difficulties you may be experiencing with your insurance revenue management. We work and bill directly from your software, and our knowledge and experience in different software programs now exceeds more than a dozen programs! We also post your payments for you directly in your software! Mention you read this e-newsletter and we’ll waive your start-up fee!
***We are pleased to announce the EHR software we work out of has expanded and now includes the following: ChiroTouch, ACOM, PayDC, EZNotes, Eclipse, ChiroHD, Office Ally, ChiroFusion, zHealth, CollaborateMD, MediSoft, Jane App, and more! Don’t see yours on the list? We continue to expand every month! Call to find out more!
Yours in health and wealth,
Dr Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
eNewsletter 03122024
Cracking the Code: Navigating HEDIS, the Future of Low Back X-Rays, and a Possible Voice to Controvert
Dear Doctors, Therapists and Staff,
Ah, the joys of healthcare bureaucracy—where navigating through a maze of regulations can sometimes feel like deciphering ancient hieroglyphics (my apologies to hieroglyphics for the comparison). Enter HEDIS, the Healthcare Effectiveness Data and Information Set, a set of measures designed to keep us all on our toes, especially when it comes to determining the necessity of diagnostic procedures like low back x-rays. If you’re seeing low back x-ray denials from the likes of Blue Cross Blue Shield or Cigna read on!
First, let’s take a stroll down memory lane and uncover how HEDIS came to be. Picture a boardroom filled with suits, each one armed with a spreadsheet and a mission to standardize healthcare performance metrics. Voila! HEDIS was born—an acronym that strikes fear into the hearts of providers everywhere, like a required Part 7 of a National Board Exam (there isn’t one, but had you worried!).
Now, fast forward to the present day, where insurance companies wield HEDIS criteria like a double-edged sword. On one hand, they claim to champion quality care and cost-effectiveness. On the other hand, they’re silently rubbing their hands together, plotting ways to restrict access to diagnostic imaging to save a few bucks. HEDIS measures are supposed to serve as a yardstick for evaluating the performance of healthcare plans. As far as specialties like Chiropractic, HEDIS holds particular significance, especially when it comes to determining whether diagnostic imaging is necessary for conditions such as low back pain. HEDIS has sparked discussions about whether there should be coverage of low back x-rays as a medically necessary procedure. According to HEDIS, the decision to cover or not to cover hinges on factors such as severity of symptoms, the presence of red flags, and the effectiveness of conservative treatment.
Furthermore, within the HEDIS guidelines it is felt that diagnostic imaging studies for low back pain that are taken within 6 weeks of the initial visit are, in essence, medically unnecessary unless there is reason for the provider to suspect something much more serious such as cancer or an infectious process. It states that most low back pain sufferers recover within 6 weeks with conservative treatment, such as exercise, pain meds and physical therapy, and that low back diagnostic imaging would serve no additional benefit.
So, what does this mean for us Chiropractors? Well, brace yourselves, because these x-ray restrictions could throw a monkey wrench into our practices faster than you can say “subluxation” three times fast (you just tried it didn’t you). Suddenly, our hands are tied, forced to rely on outdated clinical guidelines and guesswork instead of hard evidence.
But wait, it gets better. Picture this: You’ve got a patient hobbling into your office, clutching their lower back like it’s a Saturday night winning lotto ticket although without the joy. They’re in agony, begging for relief. Normally, you’d order or take a low back x-ray without a second thought, but thanks to HEDIS, it’s a game of Russian roulette. Will it be covered? Will you have to jump through hoops to justify it? Would that even matter under HEDIS protocols?
And what about patient safety! Without timely access to diagnostic imaging, we’re flying blind, unable to rule out those potentially serious underlying conditions or tailor our treatment plans accordingly. In my early years in practice I had a patient present with severe low back pain and upon taking x-rays I discovered a massive abdominal aortic aneurysm. A seemingly innocent lumbosacral adjustment could have had devastating results. Not being able to utilize diagnostic x-rays at our professional discretion is like trying to navigate a minefield in the dark—risky business, to say the least.
So, what’s a Chiropractor to do in these trying times? Well, for starters, we can arm ourselves with knowledge, staying informed about the latest HEDIS updates and advocating for sensible healthcare policies. Pay attention to denial remarks on EOBs and ERAs for diagnostic x-rays that might actually state HEDIS as the denial protocol used [it might even mention the non-use of the 6 week cooling off period]. We can also flex our collaborative muscles, partnering with other healthcare providers such as primary care providers, orthopedists or neurologists that may also be involved in a case to ensure our patients receive the care they deserve.
It’s also imperative that your examination findings and documentation be complete, descriptive and supportive of the need to take those diagnostic x-rays right away. Any doubt, any absence, any lack of evidence to support your rationale for those films and the insurance denial based on HEDIS is inevitable.
There are other voices I would like to see speak out to help controvert systemic use of a denial protocol like HEDIS, or managed care plans that contractually deny Chiropractors coverage not only for diagnostic services, but simple examinations. I would be overjoyed if our malpractice carriers publicly weighed-in on these draconian measures by formally expressing to these insurers the importance of performing these services for the safety and protection of both patient and provider; as well as how these measures place a burden on their policyholders that could jeopardize their liability coverage should something go awry, and that could have been prevented if the diagnostic service had been performed.
In conclusion, HEDIS may be a thorn in our side, but it’s up to us to rise to the challenge and champion the best interests and safety of our patients. So, here’s to cracking the code, navigating the maze, and emerging victorious on the other side—x-ray restrictions be damned!
Think you might require billing and collection services? Call us for a no obligation chat to discuss your needs, or any difficulties you may be experiencing with your insurance revenue management. We work and bill directly from your software, and our knowledge and experience in different software programs now exceeds more than a dozen programs! We also post your payments for you directly in your software! Mention you read this e-newsletter and we’ll waive your start-up fee!
***We are pleased to announce the EHR software we work out of has expanded and now includes the following: ChiroTouch, ACOM, PayDC, EZNotes, Eclipse, ChiroHD, Office Ally, ChiroFusion, zHealth, CollaborateMD, MediSoft, and more! Don’t see yours on the list? We continue to expand every month! Call to find out more!
Yours in health and wealth,
Dr Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
www.icollectmedicalbilling.com
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eNewsletter 02202024
From: Dr. Art LeVine @ iCollect Medical Billing
Navigating Medicare Changes for Chiropractors and Physical Therapists in 2024
Hello Doctors, Therapists and Staff!
If you haven’t gotten the love from me before let me say again, happy 2024, and nothing but blessings to you and yours this year, and every year hereafter!Speaking of hereafter, I know what you’re here after, which is a little information to help get you through another day in the rough and tumble world of insurance! In this go-around I’m going to focus on more of a reminder for both our Chiropractic and Physical Therapy offices. We’ve had several offices comment to us about values they are using for 2024 Medicare deductibles. The problem is that they are citing 2023 values and not the new 2024. So, I’ll address that and a couple other items in this e-newsletter. Let’s get to it!
In the dynamic landscape of healthcare, staying well-informed about Medicare Part B updates is crucial for Chiropractors and Physical Therapists. As we step into 2024, let’s delve into key changes in Medicare Part B and therapy service thresholds that directly impact these specialties.
Medicare Part B Annual Deductible:
For 2024, the annual deductible for all Medicare Part B beneficiaries is $240. This represents a modest increase of $14 from the previous year’s deductible of $226 in 2023. Chiropractors and Physical Therapists should communicate this information to their patients, ensuring transparency about potential out-of-pocket costs at the beginning of the year [Don’t forget about the “No Surprises Act”, too!].
Understanding the annual deductible is vital for all practitioners, as it directly affects billing processes and financial planning for both the healthcare provider and the patient. Being aware of these changes allows for more effective communication with patients regarding their Medicare coverage and potential financial responsibilities.
Therapy Services: Per-Beneficiary 2024 Threshold Amounts:
For 2024, Medicare introduced specific threshold amounts for therapy services. The KX modifier is applied to indicate that the services provided are medically necessary and meet Medicare’s criteria for coverage beyond the standard limits.
For 2024, the threshold amounts for therapy services are:
1. Physical Therapy and Speech-Language Pathology Services Combined:
· Threshold Amount: $2,330 – a $100 increase over 2023.
2. Occupational Therapy Services:
· Threshold Amount: $2,330 – a $100 increase over 2023.
Practitioners offering physical therapy, speech-language pathology, and occupational therapy services should take note of these threshold amounts. Once these thresholds are reached, the KX modifier becomes essential to continue receiving reimbursement for services deemed medically necessary. Any services billed after the threshold is reached, but missing the KX modifier will be denied.
It is crucial for Chiropractors and Physical Therapists to closely monitor their patients’ progress and ensure that documentation supports the medical necessity of continued therapy services. Additionally, effective communication with patients regarding these thresholds can help manage expectations and address potential financial considerations.
In light of Medicare’s strict documentation requirements, Chiropractors and Physical Therapists must maintain thorough and accurate records of patient encounters. Detailed documentation not only ensures compliance with Medicare regulations but also supports the necessity and effectiveness of the services provided. This documentation should include assessment findings, treatment plans, progress notes, and any relevant communication with other healthcare providers.
In conclusion, staying informed about Medicare Part B changes and therapy service thresholds is integral for Chiropractors and Physical Therapists in providing optimal care while navigating the evolving healthcare landscape. By understanding the annual deductible adjustments and therapy service thresholds, practitioners can enhance their financial planning, improve patient communication, and continue delivering high-quality services in 2024.
Think you might require billing and collection services? Call us for a no obligation chat to discuss your needs, or any difficulties you may be experiencing with your insurance revenue management. We work and bill directly from your software, and our knowledge and experience in different software programs now exceeds more than a dozen programs! We also post your payments for you directly in your software! Mention you read this e-newsletter and we’ll waive your start-up fee!
***We are pleased to announce the EHR software we work out of has expanded and now includes the following: ChiroTouch, ACOM, PayDC, EZNotes, Eclipse, ChiroHD, Office Ally, ChiroFusion, zHealth, CollaborateMD, MediSoft, and more! Don’t see yours on the list? We continue to expand every month! Call to find out more!
Yours in health and wealth,
Dr Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
www.icollectmedicalbilling.com
*Want to share this masterpiece with the masses? You have excellent taste! You have my permission, but it must be shared as is with my signature and contact info [just in case it gets lost it will find its way back]!
**Don’t want to receive such riveting information any longer? Think you can handle your insomnia on your own? Well, go in peace…but first, reply to this email with “Remove” in the subject line. Don’t mind me as I cry myself to sleep!
eNewsletter 06282023
From: Dr. Art LeVine @ iCollect Medical Billing eNewsletter 6-28-2023
Hello Doctors and Staff,
I hope this eNewsletter finds you happy and healthy!
In case you were unaware, 6/30/2023 marks the date you must put into use the new CMS Advance Beneficiary Notice [ABN] form. This form has a tentative expiration date of 1/31/2026 (I say “tentative” because we are talking about the government, right!?). I have placed the CMS link to download the ABN form, in both English and Spanish, below.
Please remember that the ABN form is only meant for those services that are normally covered by Medicare, but where the provider feels Medicare will not reimburse because the provider has deemed the service maintenance care. For Chiropractic this would exclusively cover the three spinal manipulation codes [98940, 98941, 98942] which would be billed with the -GA modifier, instead of the -AT modifier which is only applicable for active care and not maintenance. The ABN form is NOT meant to be used for all other services, which are considered “statutorily non-covered”. In my opinion and experience, it would be a very smart and prudent idea to create a form on your letterhead that basically says something like,
“Dear Patient, Dr. ______ has deemed that the following services are [important, necessary, integral, etc] to determine the cause and extent of your condition (ie, exams, xrays, etc); also, the doctor has deemed that the following services are [important, necessary, integral, etc] to speed and improve your recovery [physical therapies, strapping/taping, braces, etc].
Medicare has stated these services are “statutorily non-covered” when performed by a Chiropractic physician, therefore, you will be responsible for these charges.” Have the patient sign that form, date it, give them a copy and you keep the original.
This way, down the road, if they contest that you never informed them of this responsibility, or forget, or think they should be receiving some form of reimbursement from Medicare you’ll have the proof that you informed them of the rule, the price (based on the relatively new Good Faith Estimate requirement), and they signed the form!
Get this ready for the 6/30/23 start!
https://www.cms.gov/medicare/medicare-general-information/bni/abn
Yours in health and wealth,
Dr. Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
Past Florida Contractor Advisory Council (CAC) Representative
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
www.icollectmedicalbilling.com
eNewsletter 0221202
From: Dr. Art LeVine @ iCollect Medical Billing eNewsletter 02212023
Hello Doctors and Staff!
I hope your 2023 has started off in grand fashion and that your New Year’s resolutions are well underway!
I had wanted to get this information out to everyone towards the end of January, but the new Congress, specifically the House of Representatives, had just a couple of delays getting their own house in order. Once that side-show was seemingly over there was chatter that they may attempt to do a deep dive into chopping so-called entitlement programs such as Medicare and Social Security, and begin primarily by targeting the 2023 Medicare program mainly focusing on the fee schedule and covered benefits. Such changes could have quite the ripple-effect, especially here in Florida, as it would not only affect reimbursements for straight Medicare patients, but PIP reimbursements, and even Medicare Advantage plans. So, yours truly didn’t want to release the 2023 Medicare fee schedules to you approved by Congress in November 2022 if there was going to be another re-vamp of those figures.
As a reminder, healthcare providers were originally preparing for as much as 8.5% in reimbursement cuts from Medicare to many covered services. More than 150 provider groups and organizations successfully rallied together to petition Congress and Medicare to stop such draconian measures at a time when rising costs and inflation were already affecting healthcare practices. So, rather than an immediate 8.5% cut right away to those earmarked services a 2% rollback was put in effect for 2023, and then 1.25% for 2024. Of course, the House and Congress can shake up this etch-a-sketch box [apologies to late Millennials and Gen Z’ers – ask your parents if you don’t know what that is] and erase it all at their whim, so it’s best to digest this a year at a time and see how the literal pieces fall. Also, keep your ears open for discussions about Medicare physician payment reform to create stability in the program as was recently suggested by the current president of the AMA.
Be this all as it may, the House apparently has taken on more than what they can find common ground on, it’s past the mid-point in February, and my trigger finger to hit “Send” and get this love note out to you was beyond itchy – so here we are.
Our billing and collection clients can request the last approved fee schedule for their Locality, and all others can request the link to download their fee schedules as well.
On a tangential note, we’ve been noticing that a few offices are still using the old Medicare Part B deductible amount from 2022. Please note that the 2023 Medicare Part B deductible is $226 which is a $7 decline from 2022. This could also have an effect on some Medicare Advantage plans so be sure to verify the insurance coverage of those and all other plans. If you over-collected from your Medicare patients you must credit or return the overage amount to the patient.
Last, providers and staff must keep vigilant in watching for emails from Medicare’s PECOS system. PECOS is the Provider Enrollment, Chain, and Ownership System. Medicare, or CMS, verifies physicians’ status by using its provider enrollment database and if a physician does not have an approved enrollment record Medicare will not pay for services provided to those patients. PECOS will randomly require providers to revalidate their information in order to stay in their good graces. If you have not checked or verified your status with CMS in the past year I would strongly suggest you do so right away, and then calendar to check this site every six months to ensure your registration, revalidation, and compliance. You should check your status at https://pecos.cms.hhs.gov.
Think you might require billing and collection services? Call us for a no obligation chat to discuss your needs or any difficulties you may be experiencing with your insurance revenue management. We work and bill directly from your software, and our knowledge and experience in different software programs now exceeds more than a dozen programs! We also post your payments for you directly in your software! Mention you read this e-newsletter and we’ll waive your start-up fee!
DISCUSSION QUESTIONS
1. Have you ever visited a Member of Congress in Washington, DC? Extra credit if you were inebriated at the time. Double credits if they were inebriated at the time.
2. Did you have an etch-a-sketch growing up? Was it mine [I’d like it back, please]?
3. Do you know what percentage of your practice is affected by Medicare reimbursement rates [Medicare, Medicare Advantage, Managed Care plans that use Medicare fee schedule, PIP, etc]?
Yours in health and wealth,
Dr. Art
Dr. Arthur I. LeVine
CEO & Founder, iCollect Medical Billing Services, LLC
Past President, Florida Chiropractic Assn.,
Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
Past Florida Contractor Advisory Council (CAC) Representative
7027 W. Broward Blvd., #229
Plantation, FL 33317
954-530-6232 Office
206-309-4925 Fax to Email
www.icollectmedicalbilling.com
*Want to share this masterpiece with the masses? You have excellent taste! You have my permission, but it must be shared as is with my signature and contact info [just in case it gets lost it will find its way back]!
**Don’t want to receive such riveting information any longer? Think you can handle your insomnia on your own? Well, go in peace…but first, reply to this email with “Remove” in the subject line. Don’t mind me as I cry myself to sleep!
