Are we required to take Medicare patients?

January 15, 2008

Gosh, I guess if you spend an hour per patient, their allowable fee

would kill you. But I am able to get in and out of the treatment room

faster than that. So!!! if you only see a couple of them per day, you

are not hurting your bottom line. I can choose to eat prime rib, or a

good old fashion hamburger, and make up the difference.

I would guess all of us in practice for more than a couple of years

has our billing procedure down pretty good. I actually find that I

glean a personal benefit from just interacting with these seasoned

citizens. I don't find them a drain at all.

If you have a poor opinion of someones reimbursement plan, whether

cash or insurance, PI, WC, and yes, Medicare, it can't help but taint

your attitude toward the patient. They deserve to have someone accept

their " benefit " . In their mind, they have earned it, deserve it, and

by golly, we should accept it. (I love these folks)

Anyway, I doubt anyone is being put in the poor house by accepting

these patients unless they make up a huge % of your patient base.

And, if you are sooooo good at billing, you shouldn't have too many

problems and you should have been paid fairly quickly anyway. Again,

it shouldn't hurt your bottom line unless you have a huge % of

Medicare patients. But that doesn't seem to be the case as you say.

You can choose to see these patients, or not, in either case you are

providing a great service to all. Our practices are neither superior

to yours, or inferior to yours, regardless of how we choose to get paid.

I get really tired of people who make statements of their practice

superiority because they don't cheapen themselves by how they choose

to get paid. If they are making a good living, not cheating anyone,

and providing a good service, they are a great, compassionate, and

humane doctor. Just because you accept cash only, or PI only, or

Medicare only, you get the picture, we are all in the same boat.

So, lets stop this " I'm better than you because " stuff. I irritating,

and doesn't improve our opinion of you.

Sorry for the rant, but this kind of discussion gets my ire.

Grice, DC

Albany, OR

January 15, 2008

Annette,

Nope, bill your standard rate for any Medicare beneficiary receiving treatment for PI or Work Comp as primary. If the primary denies, Medicare as secondary will only reimburse according to their fee schedule. The remaining balance is held up until the PI or WC claim is settled. J. Holzapfel, DCAlbany, OregonPlease note: message attached

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Regarding PIP or Work Comp:

Are we required to bill medicare rates for a Medicare patient who is

under the PIP or Work comp insurance as primary? My office manager and

I went to a Medicare seminar about four years back and got the

impression that even if the accident insurance is primary, we could

only charge what medicare would pay to the accident insurance carrier,

then bill Medicare as secondary ifthe non-medicare did not pay.

I hope we are just confused.

Although, this is Medicare.

Annette

On Monday, January 14, 2008, at 08:37 PM, J. Holzapfel, DC wrote:

> I'm sorry for not responding sooner...but I'm afraid Chiropractors,

> unlike MDs and DOs are not allowed to " opt-out " of Medicare. As I

> wrote to Jo, if you treat a Medicare patient you are obligated to

> bill Noridian, regardless if you are par or non-par. The only

> exception is if the patient, of their own free will, will not give you

> their permission to bill Noridian. BUT, you better document that fact

> VERY CAREFULLY and remain prepared to send a bill to Noridian for ALL

> services provided but not billed should the patient or any of their

> legal representatives change his/her mind at ANY time. I would be

> happy to work with you to iron out any problems you may be having with

> completing the CMS-1500 assuming you are billing by paper. Yes, there

> are big problems with the system, particularly with the advent of the

> NPI. But, the process is quite simple compared to what our medical

> counterparts are required to do. Last I heard Noridian is working on

> a billing education webinar. As soon as that is available I'll let

> everyone know. Contact me at my office, 541-928-4060, or by this

> forum.

>

> J. Holzapfel, DC

> Albany, Oregon

>

> -- " deadmed " <deadmed@...> wrote:

> I gotta say,

> I had recently re-instated medicare in my office and it has been a

> nightmare. I did it as a favor to a patient. I'm still trying to

> figure out how to fill the HCFA out to their liking and have yet to be

> paid on 4 visits the lady has accumulated as well as 5 new medicare

> patients. A colossal waste of time. Now i remember why i stopped

> accepting it in the first place. I no longer feel sympathy for these

> folks. They most times require more time during history and treatment

> than any other patients. They can fork over the cash rate in my

> office for now on, which leads me to my question.

>

> HOW DO I GET OUT NOW????????????????????

>

> I don't want to accept anymore and want to drop out as soon as i am

> re-imbursed for what i've done.

>

> ph Medlin, DC

> Spine Tree Chiropractic

> 1627 NE Alberta St.

> Portland, OR 97211

>

> Re: Are we required to take Medicare

> patients?

>

> Jo,

>

> Bottom line with Medicare...if you treat a medicare recipient and

> their part B benefits are primary, you must bill Medicare (par and

> non-par alke). If another insurer is primary (eg. PIP, Work Comp),

> then of course Medicare becomes secondary and needs not be billed

> unless there is reasonable doubt as to if the primary will pay. If

> the primary denies then Medicare will require proof of denial. Even

> then, Medicare will only reimburse for manipulation and only according

> to the Medicare fee schedule. The only exception is that rare

> Medicare recipient who, " of their own free will " (and you better have

> it in writing), forbids you to bill Medicare. But even that case may

> come back to haunt you if that recipient later changes his/her mind.

> Then you are required to back bill Medicare. Be careful with any

> " senior discounts " as Medicare may consider any discount an

> " inducement " which Medicare prohibits.

>

> J. Holzapfel, DC

> Albany, Oregon

>

> -- " hrtchi " <billhartje@...> wrote:

>

> I've read that some offices in the US don't take Medicare patients at

> all. Are we, as PAR with Medicare, obligated to take all Medicare

> patients or can we tell them we don't accept Medicare?

>

> If we can tell them we don't accept, it is my understanding that we

> can't take them on as a cash patient. Am I correct?

>

> Thanks,

>

> Jo Yip

>

> Office Assistant to Dr. Hartje

>

> _____________________________________________________________

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> Hawaii.

>

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>

January 15, 2008

Hi doc,

I would not recommend an ABN with every visit. The ABN is only used for non-curative, palliative care, and only with respect to "covered charges". If your care is curative, that is for a condition that is expected to subjectively and objectively improve, and your carefully crafted chartnotes can clearly demonstrate that, then the ABN is not necessary. You must keep clear notes showing the need for the care. I have a few patients who enjoy monthly maintenance care. They sign an ABN with each visit. But, if they are reinjured or if their is a clear and measurable exacerbation or new injury we are back to "acute treatment"where no ABN is necessary. J. Holzapfel, DCAlbany, Oregon-- RMBALSIGER@... wrote:

Doc, My understanding is you can see them, have them pay you no more than the limiting charge but you are required to bill medicare on their behalf and you better have the ABN filled out for each visit or medicare can require you to refund for visits that medicare determines are not medically necessary. Please correct me if I'm wrong. Another consideration that I'm running into is that some of my patient population that I have seen for many years are aging and billing medicare is becoming a necessity for my office if I'm going to continue to see these people.

Rick

M. Balsiger, Jr., D.C.Balsiger Chiropractic Center1019 N.E. 122nd AvenuePortland, Oregon 97230503 257-8606

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January 15, 2008

(),

I totally respect your business acumen, but I’m confused about this.

If you adjust a patient in about 6 minutes or .1 hour for i.e. $26 paid over the counter and fire off a bill to Noridian, assuming $10 on average to send one bill on paper, how is that not acceptable for a limited part of patient population? (Bearing in mind some un-measurables like, time to schedule, visiting with the patient about their 40 year old daughter and 20 year old granddaughter refusing to move out of the house, and positives like referrals, supplement sales, and fruitcake at Christmas.)

We treat Medicare patients;

I am a non-par provider; just to be clear, this means we charge over the counter and bill Medicare for the pt. to get reimbursed.

Most of them don’t even expect to get reimbursed because it is a government bureaucracy.

We charge the limiting non-par fee rounded off to $26;

If the pt. needs therapies (rarely) we might perform ultrasound or trigger pt. therapy and charge $10 more;

(In which case, the patient signs an ABN informing them that they will not get reimbursed for this service prior to delivering the service.)

I have seen a published fee schedule which looks something like this:

___ 98940M-AT Adjustment Medicare -Acute care- 26.00

___ 97124-GY Trigger Point Therapy 10.00

___ 97035-GY Ultrasound 10.00

Medicare rejects 90% of our bills and sends us notices telling us that our billing is incorrect with a method INTENTIONALLY designed to make it difficult to discover what we are doing wrong. (Like telling you that you left PDX airport and you are not in Newberg, and you either made a wrong turn here, missed an exit there, etc. but no specific thing wrong.) Pathetic that they are auditing and punishing people who have not figured out how to operate this system. We tried calling a few times which was like talking to a teenager who doesn’t want to tell you where they were last night. Worse, they are headquartered in Fargo and end every statement with, “ya know” or “then”.

Our Medicare pts. See the denial letters and we tell them that we are working on it.

We give it a glance each month on about the 20th. If there is something obvious to change, we change it. If not we send in the paper HCFA’s for that month. (By the way, my spell checker, suggested “Hoffa” for “HCFA”...hmmmm. Maybe Building #7 was a controlled demolition!)

Our Medicare patients are OVER-informed about the vagaries of billing Medicare.

The ones who stay and pay, are typically fine with it. If we ever get our billing straightened out, we will throw a party!

As others have mentioned, this is a growing population which shouldn’t be ignored simply because their government insurance is awful. We try to make certain that they and others realize that this is a bad system and we are trying to work with it to bring this wonderful service to them.

What a great example of a messed up system! I was going to write a couple of lines to and it turned into a page long data dump.

I’m goin’ back to work, ya know...then.

( E. Abrahamson, D.C.)

Chiropractic physician

Lake Oswego Chiropractic Clinic

315 Second Street

Lake Oswego, OR 97034

503-635-6246

Website: http://www.lakeoswegochiro.com

From: spbkchiro97132 <spbkchiro@...>

Date: Tue, 15 Jan 2008 18:48:29 -0000

< >

Subject: Re: Are we required to take Medicare patients?

All:

We no longer bill medicare, or deal with them in any way but still

have a fair number of medicare benficiaries as patients...they pay

cash. LEGALLY. The truth is, only a PATIENT can " opt " out of medicare.

Medicare is an " entitlement " (you can use it if you want) not a

" mandate " (you must use it or else).

I will not post how to do this for the 15th time...but anyone who is

interested should get a ID and log into the OeognDCs homepage

so that you can access the bounty of archived posts that exist on the

subject.

I used to feel diffrently about medicare 6-7 years ago...I felt that

it was workable and 'doable'...but then about 2-3 years ago I actually

sat down and really looked at our office numbers...the REAL

" nitty-gritty " .

Our hourly overhead was about 100/doctor-hour (i know some of you have

much less than that, good for you) according to the last ACA random

sample survey that I have seen (it was from about 6-7 years ago) the

avg. DC overhead per doctor-hour was about 76/hour for a single doctor

office...and overhead has not gone down as we all know....so the

nationwide avg is prolly pushing up toward 100/doctor-hour. (clinic hours)

I was very good at billing medicare...our office was expert at it in

fact. I would say we were better at it than 95+% of the chiros in this

state. But even with our expertise I found that my office overhead for

dealing with medicare beneficiaries went up to about about

$110/doctor-hour due to extra doctor time and extra staff time needed.

We had numerous scenarios wherein a staff member was paid 15-17/hour

while spending a full hour chasing down 26 dollars from medicare!!!!!

After very careful analysis I found that my average collection for

medicare patients was about 125/doctor-hour...hey a profit of 15/hour!

My high school niece makes 17/hour off the books baby-sitting back in

NY.I recently paid a guy 200/hour for a coupla hours to slap morter on

our chimney!!! C'mon kids. Now granted this is only MY office, other

docs might run their office different but to the best of my knowledge

we are a pretty mean and lean operation. So, I was profiting 15/hour

per patient....and, I saw that the percentage of medicare bennies was

slowly and steadily going upward.....you see where things are going?

I envisioned an office that was 25% medicare patients with me making

15/hour on these patients!!!!!

So we got out!!!!

NO REGRETS VERY Good business decision..In fact, to stay in (for me)

would have been self-destructive, not only to me, but to my other

patients so it was the only rational decision that was possible. I was

NOT showing COMPASSION by staying in. I was NOT being HUMANE by

participating in this system.. I was just slowly DESTROYING my practice.

So nowadays we see a smaller number of medicare-eligibles, bout half

as many as before (the folks have chosen to opt out of their own free

will...these are very pleasant and responsible seniors BTW, most of

whom work out and have a positive mindset and are NOT walking chemical

expriments etc.) but we operate at about 80/hour profit margin with

them...very SUSTAINABLE.

:-)

Finally:

Every office is unique..some of you might be making 30-60/doctor-hour

profit or more off of these patients...others might be more like

us...but I urge you to check out the bottom line in your individual

case..the 'bottom line' for us was this: Medicare was UNSUSTAINABLE

and therefore DESTRUCTIVE and therefore UNACCEPTABLE. So we are done

with that bone-headed, screwed up, deMENTED system. I have never

looked back. Now if they raise the reimbursement rate by about 10

dollars per adjustment, we will re-visit.

P.S. The ICA is the only chiro organization with a sane attitude

toward medicare. They have consistently pushed and asked for a change

in federal law that would simply allow chiros the same option to opt

out that MDs already have. But the ACA has fought that approach and

pushed for MORE inclusion into a system that is very difficult to make

a fair profit in.

Cheers.

>

> I've read that some offices in the US don't take Medicare patients

atall. Are we, as PAR with Medicare, obligated to take all

Medicarepatients or can we tell them we don't accept Medicare?If we

can tell them we don't accept, it is my understanding that wecan't

take them on as a cash patient. Am I correct?Thanks,Jo YipOffice

Assistant to Dr.

Hartje__________________________________________________________Dreaming

of getting away? Click here for an island experience in Hawaii.

>

> __________________________________________________________

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>

January 15, 2008

I was in between pts and didn't have full time to respond. But every ofc is different. But most docs are deluding themselves. You cant guess your way thru this. You have got to look at the real figures not just guess that it take 10 bucks per claim etc. ACA did a randomized nationwide practice survey...these stats are not published because they are so dismal...but you can buy the report from them. The last one I saw (6-7 years ago) showed nationwide avg something like this

180k/year collection (3750/week)

100k/year overhead (2083/week)

25 hour per week worked clinical

86 pv/week

3.44 pv/hour

$43.6 /pv collected

$24.22/pv overhead

19.38/pv profit

$66.67/hour profit

You can look at all the non-randomized practice surveys that you want (mostly done by trade magazines), but these surveys are biased and non-scientific, but the ACA's is randomized and larger sampling etc.

All I am saying is that my guess is that if MOST (not all) docs did the thorough analysis that I did, they would find that they are collecting lower on the medicare folks (how much lower, I dunno) and that they are spending more time clinically and staff-wise. So, that hourly profit is NOT going to be 66.67/hour......but more like 40 or 30 or even 20 or like in my case 15/hour ($3.75/pv)

How would you like to an office full of patients that you profit $3.75 per visit? That is where I felt we were headed, so I bailed. i AM VERY HAPPY. ;-)

I would go thru ALL of your numbers and then take a look at what you are really profiting.......dont use this .1 hour (6minute per pt) crap unless you never do exams, re-exams etc and are truly seeing 250-280pv/week. It might turn out that you are turning