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Good afternoon. My name is Yvette Noel. I’m a certified professional compliance officer. I am the education director for KMC university. I’m so glad that you could join me today. We’re going to be talking a little bit about Medicare everybody’s favorite topic, but as their education director, I have the opportunity to sit in on every new client that comes into KMC university. One to find out how we can better serve you and to, to find out any areas of risk and the practice. Most time I hear something that has to do with Medicare and those, and we always have that opportunity to help you get that cleaned up right away. And some of what I’m going to be discussing today is something new that we have seen. Well, not really new. It’s been around for a while, but a lot of it’s taken a resurgence and it’s concerning to us as a compliance company. I came to KMC university back in 2016, while serving here, I’ve served in the capacity of membership advisor. And then as the senior membership advisor and then moved into this job role of being the education director. And it is a great honor. I really do appreciate Kyra secure for inviting us to be with you today. We’ll look forward to spending some installments with you and I’m ready to get started if you are. So let’s go ahead and go on over to those slides together.
Well, we go to the slides today. You’re going to notice that we will be talking about to be in or not to be in with Medicare, taking a little bit Shakespeare on us today, but definitely want to talk about that. Very topic, have a couple of other things that we have on the agenda. We’re going to discover why it is mandatory for a chiropractor to be enrolled with Medicare. If you’re going to touch and Medicare patients, everybody’s kind of in shock. Don’t worry. I talked to a lot of people that are in shock that just thought they could get by. Well, what about if I do this? Or what if I do that? What about if you do, then we’re going to recognize the different types of Medicare coverage that are available for your beneficiaries to choose from and how you may want to react.
We’ll just do a little Britt high overview of that. Talk a little bit about qualified Medicare beneficiaries when we’re talking about, we’ve got to also think about even those types of Medicare beneficiaries. And then finally, we’re going to speak just a little bit about some hidden dangers with box 24 J it’s on that CMS 1500 form. And it all really does tie together here. So let’s go ahead and just dive right in. We want to make sure that anytime we say something at KMC university, you know that we’ve got something to back it up. And a lot of people say, but I was told this, but I was told that. And we’ll say, you know what? We’re not just saying it. We’re actually giving you the reference in documentation and regulations, guidance, statutes, and such. So we can see here that you must be enrolled to touch a Medicare patient.
When we look at that bullet point, it says the opt out law does not define a physician to include chiropractors. Therefore they may not opt out of Medicare and provide services under private contract. Don’t feel bad and don’t feel left out. They also do this to physical therapists and occupational therapists that are in independent, independent practice. And you can see there, it gives that explanation, but here it’s quite plain. This is why we are asking for some equality for us as a group of physicians so that we can opt out my opinion. You get a lower error rate because a lot of people would just opt out. They don’t want to deal with all that headache of documenting this way or documenting that way or doing it this way or getting the modifiers, right. Everybody wants to get it just right. And sometimes it seems like it would be easier to not deal with Medicare, but unfortunately, if you’re going to touch Medicare patient, it now is the reality of your practice.
So you say, okay, you bet. You’ve just shocked me. I didn’t realize that I’d always heard. I could just kind of stay out. I don’t have to be in and please tell me what I have to do today. Great news is KMC university can help you with it, but here’s some starting points. Of course, these are just some high level things you’ll want to establish your business with the IRS. I may have someone new. That’s just graduating from college or getting ready to congratulations to you as you start your new practice, but you gotta establish a business with the IRS as a starting point to dealing with any insurance and just having a business period next would be, you’re going to apply for a type one MPI, meaning you as an individual need to have that HIPAA number that allows you to talk between your practice and the clearing house and the payer.
All that just gets all wrapped up in that MPI. It’s that nice way to identify you without having to throw your social out there all the time next down, we’ll determine are you going to be par or non-par? There really is a very fine line in the differences between par and non-par. And it’s really about the money you’re still going to have to bill. You’re still gonna have to document and modify and everything. Same. The only difference is is as a non-par provider, you can say, huh, I’m going to accept assignment on these people, or I’m never going to accept assignment. You still have a fee that you’re limited to. You’re still having a document submit, use the ABN forms correctly. Everything’s the same. So when it comes down to being part or non-par, it is all about payment, it is so confusing. Those two terms, because with those two terms, if you’re talking about blue cross and blue shield, it’s simply saying I’m in, or I’m out with Medicare.
It’s, I’m enrolled, I’m not enrolled. And if I’m enrolled it’s par or non-par. So that is a confusing term to learn also the next to be apply for credentialing. Now, when we go to apply for credentialing with Medicare, the stat tax status will determine had we needed a type two NPI. In addition to the type one, if our business is structurally set up as some type, maybe we can get by with just having a type one. And we may only have to credential as a individual provider, but in most situations, and especially if you’re going to be adding any, any future DCS to your practice or any others that could enroll with Medicare, you’re going to set up as a group and there you will have to have the type two NPI. Then you’ll have to enroll each provider. This is where I really thought this was great to bring to this topic today is because we’re noticing a trend that came to the university.
It was probably about two to three months ago, eight out of nine calls. It was just all in one clump. For some reason, we were getting a lot of practices that had heard that only doctor a needed to be enrolled with Medicare. And then dr. BC and D could ride on his skirt tail. That’s why our box 24 J is going to come in later in this conversation that is wrong. If this doctor’s going to touch, he has to be enrolled. If B, C, D, E, and F are going to touch, they have to individually be enrolled. And what will happen when you do their enrollment, they will go in with their type one and come up under your type two, your tax ID with Medicare as part of a reassignment, they will then, and you will wait for approval from Medicare before seeing any Medicare patients.
At that time, you’ll be given a P tan. Don’t try to call a Medicare without it. That’s just going to be my, my plus of the day. Don’t call Medicare without a P tan. You don’t get very far. And when you apply to become a provider with Medicare, generally is going to take you about 90 to 120 days. Start training to learn how to deal with Medicare, just to turn on the switch and just start doing it the way you’ve been doing it. You’re going to get denial after denial, after denial, because there’s modifiers, conditional modifiers. You have situations where things are excluded. You have to use those particular modifiers start training. Now, Yvette, I didn’t know this. I’ve been doing it wrong. Guess what? Start doing it right now. Stop seeing those Medicare patients get enrolled, get trained and go forward. These are the people who fill up your schedule from nine 30 to 1130 every day.
Now there’s an art to it. Once you are enrolled, you have to stay active. So I thought we’d have a little bit of John Travolta singing to us here, staying alive, staying alive, I’ll stay alive. And Medicare gives us a couple of ways and a couple things we have to do to stay alive. Some practices may be more wellness spaced. Maybe you never provide a service that Medicare considers to be covered, which is the spinal CMT. In those situations. You’ve got to bill Medicare, at least one time a year, stick your hand up out of the dirt and say, Hey, Medicare, I’m still alive. Use the appropriate modifiers, do everything you’re supposed to do when submitting a claim to Medicare and just let them know you’re still there. They’re a little slow to the punch sometimes. And they don’t always throw you out at 12 months, but their rule says right here, you can see an, a number one that they can sell you out after 12 consecutive months of not billing, Medicare big risk, and they will deactivate your account.
There’s one other way that this can happen. And we’re finding it about every five years. They’re going to ask you to revalidate, and they’re trying to sync up your practice in your individual at the same time. So you’re not doing your practice here and individual off here two and a half years later, but they’re trying to get those sinked, but it’s always important to be paying attention. They generally will send you a notification, check your email, the excuse of I didn’t get it does not work. They will kick you out. And again, you will have a deactivated account. And we know you got to be actively enrolled with active billing privileges to see a Medicare patient. And without it, you can’t see them. Now that we’re enrolled, we’ve stayed active. We’re going to talk about a little bit of the differences of the different types of Medicare payers.
So do you know the difference, Medicare, Medicare advantage QNB OMI. We’re going to take a little bit of a deeper dive. When we talk about the types of Medicare coverage, we’re going to focus because we just have a little bit of short time here together on part B and part C. We can see here though, that part a is going to be hospital and part D is going to be more of that Medicare prescription drug plan. Part B is where we live as chiropractors. If there’s physical therapists listening in your businesses, your S your little doctor’s offices here and there, we’re going to fall under that part. B part C is the Medicare advantage plan where the patient elects to go get something else, or maybe they had a Medicare plan. And like here in West Virginia, where I live, they took the Pia, which is the public employees and push that together.
And that became a part C a that just kind of merged is the most beautiful product I’ve ever seen. They have the best coverage I’ve ever been witness of, um, to date. They actually have some habilitative coverage. Part B is optionable. So just because they have that red, white, and blue card, you do need to be checking, but as usually their primary coverage, not always. And I’ll take just a quick second and a moment to talk about that. This is the new Medicare beneficiary card. You should have already updated all of your Medicare ID in your software to be billing to Medicare with this new MIB, MBI Medicare beneficiary identifier, you can see the structure has got the name. One thing. When we noticed denials coming in here at KMC university, we just don’t automatically go down to box 14 and below. Sometimes we have to look at box 14 and above 13 and above, and see that the name simply isn’t how it is on the card.
We have to make sure that we have that name precisely as it is sane, and that everything matches as you see it here on this Medicare card, making sure to use that new number. They were slow to the punch, where they were using the social security number, NAFA character. But if those are still in your system, you’ve been getting denials. It doesn’t matter when the date of service was at this point. Now you’re required to be using the NBI number for any claim, any date of service that’s being submitted after January 1st of 2020, and do keep in mind. Medicare has the one year timely filing rule of one year from the date of service. Medicare also has an option with some supplement carriers and some secondary to do a crosswalk. I will walk this across the street, over to blue cross and blue shield federal for this patient.
We’ll all walk this over to mutual of Omaha as a supplement, but the patient has to request that it doesn’t automatically set up. It is something that the patient has to request, and we can see that often the system through the supplemental carrier or through the secondary, and they will then send information to Medicare to get this set up to where you’ll see on the Medicare EOB, it’ll say claim sent to, and then, uh, WVP or WV BCBS. That’s what it’ll say. You’ll know that it’s automatically being sent for you. If you don’t notice that, um, if you’re in network, you’re going to have to send on over, pull that patient in and say, you know what? Not everybody may submit secondary claims. You may want to get this set up. I’ve had to do that before. And it was a game changer actually for one family, there are different types of supplements.
So I call supplements the monkey, see the monkey do, if Medicare thinks about it, supplement will think about it. Oh, you thought about this. I’ll tell you about that. Did you think about that note? Well, I’m not thinking about that. That’s a supplement. It just kind of rides along and considers sometimes the deductible and sometimes the co-insurance, maybe it’s a copay. There’s a lot of different structures. You can see here. You’ve seen people have a plan F or are you seeing people who have a plan? And there’s a lot of different things that go into that, but do you know, those are supplements and supplements do not pick up your exams, your x-rays, your PT, your nutrition services, where we may find that a true secondary, which is typically based off of an old group. Health plan may be a retirement benefit that may pick those up again.
Another good product was a traditional Medicare, federal blue cross and blue shield. It went very well together. Patients tend to not to have much out of pocket expense, but the secondary, the true secondary we’ll consider oftentimes benefits outside of just that spinal CMT service. Now, I would do want to caution you on something with the ABN form. The patient says, I want you and option one to bill Medicare. Well, they’ve got a crossover. And with Medicare, you change that 80 to a GA, but the secondary doesn’t understand that at TGA language and they pay the maintenance service. If you verify that secondary, and they said they don’t have habilitative coverage or maintenance coverage, you need to contact them. When you’ve received a payment in there, they just don’t know. They may speak the S eight, nine, nine zero that we can’t use with Medicare. That may be their language, but always keep that in the back of your mind.
Some Medicare advantages that other side of the story, the patient decided they wanted to use something else. They wanted to clump everything in one thing, they’re a, or B they’re D all that’s in one. They can elect what they want to do with that. And we’re going to take a quick peak. This is known as Medicare advantage, Medicare replacement, and it redirects benefits from traditional Medicare over to that private payer. Now, I will tell you one, that kind of blew my mind when it hit. And I said, I know, right? A RP, what did they do? It used to be a RP. Oh, that’s a supplement. And then all of a sudden, a RP comes up with a RP complete. And you’re like, uh, what just happened here? Hey, just got in on this Medicare advantage. This is why it’s so important that you verify benefits so that, you know, one Medicare, are you really the payer.
If you’re getting a denial on your EOB, and it’s talking about a managed contract, it’s likely the patient gave you their Medicare traditional Medicare card. And didn’t give you the replacement. That’s typically why you see that denial. But I know, right? They have some tricky ones out there. And I had to put the ARP complete on there because that was the woman at first came out a few years ago. It kind of blew my mind. I’m like, well, wait a minute. You just only did supplement. Be cautious. Know what you’re dealing with? The part C plans. You don’t necessarily have to be enrolled with those patients policies. If you’re not in with Humana, guess what? They’re a cash patient. If you’re not in with ARP complete, they’re a cash patient. Haven’t paid your cash rate. Let them join Kyra health USA, whatever type of discounting you do.
That’s within federal guidelines. Let them do that. Give them a super bill and send them on their Merry way. There’s no requirement to be enrolled with the supplement with the, with the replacement plan, to provide a service to those beneficiaries with that coverage. However, there are times when you may decide to sell, to submit on behalf of that beneficiary. And when you do so, be aware, Medicare advantage plans have a process that’s called deeming. The deeming can, when they have specific stipulations, as you can read here on my screen, it says, you must follow that fee for service plans, terms, and conditions. If you send it, you expected to know it. Belle deem you and being, being, being now you’re over here and having to take a contractual obligation right off and having to play with their dog and pony show because you submitted. That’s why we always recommend just use them as cash patients and let them self submit, always be aware of the deeming process.
If you call it a verified benefit, you can always ask, do you have a deeming process and make sure that you are not signing up for something that you didn’t want to be a part of, because then it’s not conditional per this patient or that patient. I’m just going to submit for this one. And not that one you’re deemed in. You’re going to submit for all Medicare secondary compliance. When we’re thinking about that there’s many, uh, circumstances where Medicare is going to be your secondary payer too much to go into today. Medicare gives some great guidance. Campsie university has great guidance on this. Actually, this was a lesson I helped Kathy with a couple of years ago and trying to figure out what will Medicare pay if they’re the secondary, there’s an art and some math that needs done on that. And we go further into that and our membership services.
But under certain circumstances, I was helping someone yesterday, just like I do. They were new to KMC university and they patient had PI and Medicare PIs. First, Medicare second. There’s a lot of roles in Medicare can make a conditional payment way too much to get into. But again, this is why you have to do verification so that you know, who is primary and who’s secondary. And if you’re one of the lucky ones you’ll get in one of those arguments, you’ll be the, a, B the C your way out person that gets to watch those two fight with each other. Who’s primary, but it’s not happening very often, but always make sure that you know who to submit to first, to not delay payment.
Now onto the QMB promised to cover it a little bit. This is going to be just kind of a high level, not dig deep. That’s what we do here at KMC. But these are people who are dually eligible for Medicare and Medicaid. They have demonstrated a financial need and their thresholds for participation in these programs have been met. They may meet it this month. They may not made it next month. They can meet it for three months and be all for three months. Something may change with their finances that takes them out of that level of poverty and throws them just back up, right outside of it, to where they only have traditional Medicare, but it’s, so it can happen on an off and on and off. So just to verify their insurance one time at the beginning of the year, doesn’t suffice when there is Q and B consideration.
So the term that’s used, uh, in between there is a lot called cost sharing, Medicare beneficiaries that are QNB have cost sharing oftentimes for their premiums, their deductibles and their co-insurance. And we can see that in 2017, 7.7 million people, more than one out of eight people with Medicare we’re in a QMB. And I will tell you that Medicare was very laxed on giving a lot of guidance on this, and even following their own roads sane for awhile. And it was kind of loose and how we got to figure out if somebody was a QMB, but there are some stiff stipulations. If you do not honor, the QMB being in that practice. And if you’re charging them on the spinal CMT services, that is a big, no, no, we’ll talk a little bit more about what you can, but I do want you to know that coverage can vary, but state now States are supposed to be setting up a way that some of them will set up a way for you to get enrolled.
And we’ll talk about that in a minute, but you can see it’s called the Medicare savings program. You’ll have the Q and B, which has the part, a part B premiums, deductibles, and copayments coinsurance. And then it kind of starts sliding down from there. They’re like, it’s a tear, it’s a tiered step program until you get up here to where you’re all the way at the federal poverty guideline. But some people may get help with the part, a part B premium part a and B. And then we get all the way up to where we’re the actual Q and B. And we can not charge them on the spinal CMT services that are medically necessary. Next month, I’m going to be talking about the ABN. There’s some specific things that came out. We actually have some questions out to Medicare. That’s just how we do it at KMC university that we want clarity on before we let it loose to all of you and give guidance, but important reminders, all original Medicare and Medicare advantage providers and suppliers, not only those that accept Medicaid must not charge individuals enrolled in the QMB program for Medicare cost sharing must not.
There are stiff penalties to pay individuals enrolled in the QMB program, keep their protection from billing, uh, and being charged even when they cross state lines. And three, I don’t care what that Cuban B tells you. Note that individuals enrolled in QNB can not elect to pay Medicare, deductibles, coinsurance, and copays, but they could under certain circumstances have a Medicare copay. How are you going to know all this? It all goes back to that root concept of that patient experience in your office. And that is called verification, verify, verify, and verify it again, waits to promote it. They came up with some stuff that I found right on their website that says how to help promote it established processes to routinely verify, verify, verify, verify Medicare patients for QMB. Now, one of the easiest ways to do this is through the HIPAA eligibility transaction system called heads, get set up on it.
If you’re not on it, they have some of the best information out there on letting you know, if someone is a Q and B or not check it frequently, determining your billing processes could be different with Medicaid. Medicare advantage plans get enrolled with Medicaid, but I don’t want to treat Medicaid patients. You know that some States have it set up. I can’t say for chores, I told you they vary state from state, but some States have a program set up where you can enroll just to get the Q and B stuff taken care of. And it doesn’t open the door to make, you have to do all Medicaid. So do check with your state. I found several States while I was investigating this that have this kind of half in just to get that adjudication for Medicare. And one thing that I found was even if your state does not have coverage, Medicaid coverage for chiropractic, the Q and B actually says that it has to pick it up.
It’s right here. It says services not covered. Ed, as noted earlier in this informational bulletin and Medicaid agencies obligation to adjudicate and reimburse providers for Cuban, because sharing exists, even if the service or item is not covered by Medicaid, irrespective of whether the provider type is recognized by the state plan or whether or not the QNB is eligible, read it for yourself. It’s out there to see. So can you bill for your statutorily excluded services to a Medicare beneficiary that has QMB you better because you can’t offer service for free. They might qualify for your financial hardship. Maybe they chose your discount medical plan, but yes, yes, yes. You must charge them for the other services to not be caught as having an inducement, trying to get somebody to come to your practice. You’re just trying to be nice, but it can all be misconstrued.
That’s why you get it spot on, get it the way it needs to be. Write a policy. Everybody gets trained and we just move forward. So that brings me to my final thing that I want to cover with you today. And that is going to be the hidden dangers of, uh, of the box 24 J. So when we’re talking about the hidden dangers of box 24, Jay, that was exactly what I was mentioning back in the very beginning. And that is every doctor in the practice has to be enrolled with Medicare. That means if you touch the patient, dr. A your NPI individual goes in box 24 J. And if dr. F touched him, it’s his NPI that goes in 24, J of course, 32 and 33 is your practice. That’s set up, you’ll get your payment. That 24 J is certifying. I am the one who touched that patient to date.
It was me. It wasn’t an imposter. It wasn’t somebody else pretending to be me using their number, just so we can get paid. And they don’t have to enroll. Who wants to go through that hassle? You better go through the hassle because they say you have to be enrolled to touch them. Box 24. J the reason I’m stressing this today is because this is something we’re seeing right and left. I’m seeing practices that have bought somebody else’s practice, not be set up with Medicare right now using someone else’s tax ID, using someone else’s NPI, just to get payment. You can’t do that. You have to be enrolled. And if you touch them, your box 24 J locum tenants, that’s your only exception fee for time of service compensation. There’s rules there. We’re not covering that today, but make sure you’re covering it. Box 24 J you can see it right there on the screen.
That’s who touched the patient. If everyone is enrolled, but you keep using the same doctor in box 24, Jay, guess what you just did. Think back earlier in my conversation, you just deactivate a, B, C, D, and F doctor. So 24 J is who touched that patient today. Always make sure that you have that spot on. Now, like I told you, a lot of stuff just came out about that new ABM form you have until August 31st to implement the new one, we are asking from Claire, for clarity, for Medicare, they did give additional clarity in their ABN guidance this time around. That was very nice to see, but there’s still some questions to be asked, and we have those questions out. We’ve already had one of them answered. And before I come to you and give you more instruction on the ABN form, we want them all answered because KMC university absolutely insists on accuracy.
So do you just wonder about your practice that I spark according you today to just make sure you’re dotting your I’s and crossing your T’s, and maybe you’re looking at denials and maybe you don’t understand why this or that is happening with Medicare or anything else in your practice we offer as part of today, uh, for those attending through Kyra secure to do one of our discovery consultations that are typically $79 for just $49. And with this $49 investment, you’ll speak probably to me as your specialist or to one of our specialists that will help to get to the bottom of what’s going on. Kinda like taking the history and exam and intake, and we’ll set a personalized treatment plan for you. Do you need to be in some acute care with the coach, or do you need to just be in here under some supportive care to where you are able to ask?
What questions I ask that you just reach out to KMC university it’s www.kmcuniversity.com or give us a call at eight five five eight three two six five six. Two mentioned that you saw us here on the Cairo secure webinar, and that you’re signing up for your discovery consultation for just $49. Again, any questions you may have, you may reach out to firstname.lastname@example.org or call (855) 832-6562. Any questions that you have, I definitely would welcome them, would love to speak to you. And I want you to make sure that next week that you’ll join up with us for dr. Sherry McAllister. And she’ll be speaking from the foundation for chiropractic progress. She’ll be right here with you. This was Yvette Noel, the education director for KMC university, also a certified professional compliance officer, not a whole lot of us in the world, but, uh, just looking forward to seeing you again this month, when I’ve already told you that the topic is going to be on that brand new ABN form, just to make sure we’re getting it out to you just in time before that deadline. Thank you so much for joining me. And I hope you have a beautiful day