It’s that time of year again when patients and healthcare providers have a chance to change their Medicare enrollment. It can be a confusing and overwhelming time, but we’re here to help you understand how to navigate this period for both your practice and your patients. Between October 15 and December 7, patients may choose to switch from traditional Medicare Part B to Medicare Advantage Part C or vice versa. If your office is not prepared for these changes, chaos can ensue. Likewise, providers may choose to change their participation status in Medicare Part B until December 31, 2023. Should you switch? Read on to make an informed decision.

Parts is Parts-Knowledge is Power

Before we dive into how chiropractors can make the open enrollment period easy to navigate, it’s crucial to have a solid understanding of the Medicare program. Medicare is a federal health insurance program primarily designed for individuals aged 65 and older and for some younger people with disabilities. It is divided into four parts:

  1. Medicare Part A: Covers hospital care, skilled nursing facility care, hospice, and home healthcare.
  2. Medicare Part B: Covers medical services and outpatient care, including doctor visits and preventive services.
  3. Medicare Part C (Medicare Advantage): Provides an alternative to Original Medicare by offering private insurance plans that include both Part A and Part B benefits and sometimes prescription drug, vision, and even dental coverage.
  4. Medicare Part D: Focuses on prescription drug coverage.

Chiropractic services, such as manual manipulation of the spine to correct a subluxation, are typically covered under Medicare Part B but only when deemed medically necessary by Medicare’s definition. It is the only covered service under Medicare Part B. All other services are statutorily excluded and the responsibility of the patient. However, when a patient chooses Medicare Part C, other services are sometimes covered under the plan, depending on the provider’s level of participation.

Part B:  To Participate, or Not to Participate: That is the Question

 Let’s be clear about this important point:  Provider participation differs from enrollment. Chiropractors are one of three provider types that may not “opt-out” of Medicare. This means that to treat a Medicare patient or a covered or excluded service, one must be properly enrolled with the Medicare Administrative Contractor (MAC) for your jurisdiction. This covers Medicare Part B. There is a choice to be “participating” vs. “non-participating.”

  • A participating provider agrees to accept claims assignment for all Medicare-covered services to your patients. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You may not collect more from the patient than the Medicare deductible and 20% coinsurance amount. You can choose to bill any secondary or supplemental plan the patient has for the additional 20% up to the allowed amount.
  • A non-participating provider must follow all the Medicare guidelines and submit billing for active treatment but may charge Medicare’s “limiting fee” and be paid at the time of service. These providers have a choice about whether to accept assignments on a case-by-case basis, but when accepting assignments, they are limited to a lesser amount, called the “non-participating allowed fee.”

Note that either way, chiropractors must be properly enrolled, as participating or non-participating, and must submit billing on behalf of the patient. There is no option to see these patients as self-pay for active treatment. For those practices that identify as “cash-based,” the non-participating option is usually best, as the patient is paying at the time of service as all other patients do.

If you wish to change your Part B participation status for 2024, here is some helpful information to assist you. Remember, you must do so prior to December 31, 2023.

Part C Medicare Advantage:  To Participate or Not to Participate, that is the BIGGEST Question

One of Medicare’s most confusing aspects is that Medicare Advantage (Part C) plans are taking off, especially with patients. A recent poll indicated that more than 50% of patients are expected to choose a Part C Advantage plan in 2024. There are serious implications for your office, and one must be informed before making these decisions. It’s easy to understand why…the coverage is very similar to commercial coverage without the costs to the patient. In Part B Medicare, the patient may have to purchase a Medi-Gap or supplemental plan with a high premium, whereas in Part C, it’s all included.

However, patients often switch and purchase these plans, not knowing exactly what they are buying. Therefore, as a practice, it’s best to be up to speed on what this means for your revenue cycle. Advantage plans come in all shapes, sizes, and names, such as Medicare Advantage, Medicare Complete, Medicare Preferred Provider Organization (PPO), Medicare Health Maintenance Organization (HMO), Medicare Private Fee for Service (PFFS), and Medicare Point of Service (POS). It’s critical for providers to know which of these plans may provide chiropractic coverage and which won’t.

As providers, participation in Medicare Advantage often comes attached to participation in corresponding commercial plans. For example, participating in Aetna’s commercial provider network may automatically enroll the practice in the Advantage plan. If it is an HMO plan, for instance, if you are not a participant in the plan, you may not have mandatory billing requirements. Therefore, it’s crucial to always verify the patient’s plan for the most up-to-date information. From there, the practice can decide about its participation status.

A best practice is to re-evaluate which plans the practice participates in and confirm contractual obligations before the end of each calendar year. Removing the practice from these networks may take longer than with Part B and may be completed at any time during the calendar year. We also recommend that starting in December, each Medicare patient is asked about 2024 participation in Part B vs. Part C. Sometimes, they even have their new cards, and verification can occur early. Either way, we urge you not to bill Medicare services for patients whose coverage for 2024 has not been verified. That will save time and effort that may be wasted by billing the wrong payer.

What About Orthotics for Medicare Patients?

Chiropractors must understand the billing and coding process for chiropractic services under Medicare. There are only three covered services when ordered or delivered by a chiropractor. Be sure to use the appropriate codes when billing for chiropractic services: 98940 (chiropractic manipulative treatment, 1-2 regions), 98941 (chiropractic manipulative treatment, 3-4 regions), and 98942 (chiropractic manipulative treatment, five regions). Any other service or item of durable medical equipment, such as stabilizing orthotics, is never covered and excluded by Medicare when ordered or delivered by a chiropractor. However, as an excluded service, patients may elect to pay out of pocket for these necessary orthotics. Here are some important facts:

  • Orthotic inserts are covered by Medicare only when placed in a shoe attached to a brace. Foot Levelers functional orthotics are usually not placed in a shoe attached to a brace and are a non-covered service under Medicare. Dispensing providers must register with Medicare to bill as a DME supplier and receive a prescription from an authorized provider.
  • Whether Part B or Part C, we urge you to verify benefits the same as you would with any other payer class. There may be no clear path to coverage when orthotics are ordered or dispensed by a Chiropractor. These patients are unlikely to have any benefit for orthotics under their plan.

Prescribe orthotics when necessary for Medicare patients as you would with any other patient. Discuss that they are excluded under their benefit and work out a favorable payment plan to allow the patient to live their best life, properly stabilized from the ground up. Click HERE to access some additional information about payment plans. 

Proactive Education Wins the Day

One of the most critical roles offices can play during the Medicare open enrollment period is to educate their patients about their Medicare options. Here are some essential steps we can take to help their patients make informed decisions:

  1. Review patients’ current plans: Encourage your patients to bring their Medicare cards and insurance documents to their appointments. Review their current plan to ensure it covers chiropractic services.
  2. Explain the different parts of Medicare: Provide a clear and concise explanation of the different parts of Medicare, emphasizing that chiropractic services are typically covered under Part B.
  3. Discuss Medicare Advantage plans: Some patients may consider Medicare Advantage plans offered by private insurance companies, which can provide additional benefits. These plans can include chiropractic services, but patients must be aware of any restrictions, co-pays, or networks.
  4. Clarify out-of-pocket costs: Explain the potential out-of-pocket expenses, such as co-pays, deductibles, and coinsurance associated with chiropractic care. Ensure patients understand how these costs vary between Original Medicare and Medicare Advantage.
  5. Emphasize the importance of network providers: If a patient is considering a Medicare Advantage plan, stress the significance of choosing chiropractors who are in-network to minimize their out-of-pocket expenses.
  6. Recommend seeking professional guidance: Encourage your patients to consult with Medicare counselors or insurance agents specializing in Medicare plans. These professionals can provide personalized advice based on individual needs.

Medicare open enrollment is a crucial time for both chiropractors and their patients. By understanding the complexities of the Medicare program, educating patients about their options, staying informed about Medicare regulations, and providing support during the open enrollment period, chiropractors can ensure their patients receive the best care possible. Additionally, a strong understanding of billing and coding practices and supporting patient advocacy can further enhance the chiropractic experience for Medicare beneficiaries. Remember, an informed and proactive approach benefits the practice and its patients in successfully navigating the Medicare landscape.

 

 

Kathy (KMC) Weidner
MCS-P, CPCO, CCPC, CCCA | Website

Kathy, better known professionally as Kathy Mills Chang, is a globally recognized expert on the compliance and financial operations of a successful chiropractic practice. With 40 years of service to the chiropractic community, she got her start as a CA in 1983. Since then, Kathy has been sharing her expertise on Medicare, compliance, billing, coding, insurance, patient financial procedures and documentation with audiences around the world. A popular and highly experienced speaker, she has served on many national and state level chiropractic organizations, boards and advisory councils. She is also the owner and CEO of KMC University, which she founded in 2007.