RISK MANAGEMENT MINUTE – Navigating the Complexities of Medicare and Cash Practices in Chiropractic Care

In the evolving landscape of healthcare, chiropractors like Dr. Markson are increasingly considering the transition to cash-based practices, raising critical questions about Medicare compliance and billing procedures. This shift, while advantageous in many ways, brings forth a set of challenges, especially when dealing with Medicare patients and understanding the intricacies of superbills for non-Medicare clients. In this context, the role of a robust malpractice insurance provider, such as the ChiroFutures Malpractice Insurance Program, becomes pivotal in offering the necessary guidance and support.

Before reading any further make sure you understand this FACT: The only way to not be subject to the rules and requirements of Medicare is never to see a Medicare patient. Period. Full stop. This is true regardless of what any "expert" in chiropractic tells you. Ask yourself if they are not going to show up at your hearing to defend you or hire the attorney to defend you. 

Medicare Compliance in Wellness-Based Care

One of the primary concerns for chiropractic practitioners is understanding the correct protocol for treating Medicare patients within a wellness-based framework. A common question arises: if a practice lacks the capability to submit claims to Medicare, is it permissible to treat Medicare patients? The answer lies in federal regulations mandating the submission of billing for Medicare patients, regardless of the practice's payment model. Therefore, transitioning to a cash-based system does not exempt a practitioner from these obligations.

Dr. Markson's query about using the S8990 code for Medicare patients upon reaching wellness care is particularly noteworthy. It's crucial to understand that this code is not applicable for Medicare patients. Instead, the appropriate billing codes are the 989xx series, without the -AT modifier, once the patient transitions into maintenance or wellness care.

Navigating the ABN Form and Limiting Charges

Another area of confusion often revolves around the use of the Advanced Beneficiary Notice (ABN) form and adherence to Medicare's limiting charge. The ABN form, a critical document, is intended for services not covered under Medicare and should not be used for non-covered codes. It's essential for chiropractic practices to familiarize themselves with the proper usage of this form to ensure compliance and avoid potential pitfalls.

As a non-participating, non-assigning provider, Dr. Markson's concern about being limited to Medicare's limiting charge in a cash-based practice is understandable. However, it is important to recognize that Medicare's guidelines and limiting charges continue to apply, regardless of the practice's billing model. This underscores the need for thorough knowledge and compliance with Medicare regulations.

Understanding Superbills for Non-Medicare Patients

For non-Medicare patients, the concept of a superbill becomes relevant. A superbill is essentially an itemized form used by healthcare providers that details services provided to a patient. This document can be submitted by the patient to their insurance company for reimbursement. In a cash-based practice, providing superbills helps non-Medicare patients navigate their insurance claims independently, offering a seamless process for both the patient and the practitioner.

Provider Requirements in Chiropractic Practices

Adding to our discussion on the complexities of handling Medicare patients in a cash-based chiropractic practice, it's crucial to highlight a key aspect often overlooked: the requirement for chiropractors to be registered Medicare providers to treat any Medicare patient, regardless of the service provided. This applies to all types of care - active, wellness, or even non-covered services like soft tissue work, massage, and ultrasound.

Chiropractors face a unique situation in that they cannot “opt out” of Medicare. However, they have the choice to be either a participating provider or a non-participating provider within the Medicare system. Importantly, regardless of this choice, the same rules and regulations apply to both categories. This is a critical point of understanding for practitioners considering a shift to a cash-only model or contemplating the exclusion of insurance from their practice.

The rationale behind these stringent requirements stems from Medicare's role as a federal program. It is designed to safeguard the interests of its beneficiaries, who have contributed to this program throughout their working lives. Therefore, Medicare maintains the authority and obligation to vet its providers rigorously. Consequently, transitioning to a cash-only practice or deciding not to accept insurance does not exempt a chiropractic practitioner from adhering to the federal guidelines established for Medicare patients. This underscores the importance of thorough knowledge and compliance with Medicare regulations, reinforcing the need for a robust support system like the one provided by ChiroFutures Malpractice Insurance Program.

The Role of a Reliable Malpractice Insurance Provider

The complexities and nuances of Medicare compliance and transitioning to a cash-based practice underscore the importance of having a knowledgeable and reliable malpractice insurance provider. ChiroFutures Malpractice Insurance Program plays a vital role in this scenario, offering expert advice, risk management strategies, and answers to intricate questions like those posed by Dr. Markson.

Their guidance in navigating federal regulations, understanding billing codes, and correctly using forms like the ABN, not only ensures legal and ethical compliance but also provides peace of mind. Chiropractors are thus free to focus on patient care, knowing they have a strong support system to rely on for any queries or concerns.

Conclusion

Transitioning to a cash-based practice while ensuring compliance with Medicare regulations is a delicate balance that requires careful consideration and expert guidance. The advice and support from a malpractice insurance provider like ChiroFutures are invaluable in this journey. By staying informed and adhering to the guidelines, chiropractic practitioners can navigate these changes smoothly, ensuring both the wellbeing of their patients and the integrity of their practice.