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March 2019 News Flash

March 30, 2019

In this issue

  1. Meet Our Licensed Acupuncturist! Deb Zurcher, D.C., L.Ac.
  2. 2018 Provider Quality Bonus
  3. Fulcrum Health Annual Meeting
  4. Non-Covered Chiropractic Services
  5. New Regulatory Requirements – CMS Preclusion List
  6. Radon Testing Reminder
  7. Moving or Retiring? Let us Know!

Meet Our Licensed Acupuncturist! Deb Zurcher, D.C., L.Ac.

Deb ZurcherDeb Zurcher, DC, LAc, has been a licensed acupuncturist since 2012 and has over 20 years of chiropractic clinical experience as well as 16 years as a business owner. In 2003, Dr. Zurcher founded a multi-disciplinary clinic, Eagle Creek Wellness Center, LLC, in Prior Lake, MN. Her previous roles include; Liaison Faculty in the Clinical Ed department at Northwestern Health Sciences University, Self-Management Skills Guide then Operations Manager at MOBE. Dr. Zurcher graduated from Northwestern Health Sciences University with a Doctor of Chiropractic and a Masters in Acupuncture. She earned her Bachelor of Arts degree from Gustavus Adolphus College.

To learn more about AcuNet, Fulcrum’s acupuncture network, please visit www.fulcrumhealthinc.org/acunet .

2018 Provider Quality Bonus

As Fulcrum continues its journey to value-based payments for its network providers, the company is pleased to announce that in mid-March, it distributed $1.3M to eligible network practitioners as part of its Provider Quality Bonus Program. The provider quality bonus program is designed to recognize those providers who exhibit an approach that most closely aligns with ChiroCare’s best practices and Fulcrum’s Mission, Vision and Values. It is based upon provider tier as well as the individual practitioner’s performance for services provided between January 1 and December 31, 2018. Awards to eligible practitioners reflect client mix, patient volume, billing patterns, and efficiency of treatment provided as compared to other practitioners within the network. At this time, only ChiroCare Centers of Excellence (CCoE) and high performing Category A providers are eligible to receive a quality bonus.

The quality bonus award serves as Fulcrum’s acknowledgement of practitioner’s continued effort to provide high quality, patient centered care. This quality bonus payment is compensation in addition to that already received via fee schedule based claims payments. On average, the provider quality bonus represents a 10% increase in the fee schedule for practitioners within ChiroCare Centers of Excellence (CCoE’s) and a 6% increase for Category A providers. Additionally, Fulcrum does not withhold any claims payment amounts due to practitioners.

Click here to learn more on how your clinic may become a ChiroCare Center of Excellence.

Fulcrum Health Annual Meeting

Our annual meeting will be held on May 2nd, 2019. This is an opportunity for our network providers to learn more about what Fulcrum Health is doing for you. Additional information to follow.

Compliance

Non-Covered Chiropractic Services

Non-Covered Chiropractic Services is a pertinent and relevant issue to be covered in upcoming Compliance articles. This month we will speak to the OIG Workplan specifically.

The Office of the Inspector General (OIG) recently released updates to their Workplan which serves to identify risks across various agencies (CMS, DHS, etc.) most in need of attention. These risks are prioritized and resources slated to perform audits and reviews accordingly.

T he payment of non-covered chiropractic services is an issue still active on the Workplan. As you are aware, Medicare Part B only pays for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment (42 CFR § 410.21(b)). Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable (Centers for Medicare & Medicaid Services’ Medicare Benefit Policy Manual, Pub. No. 10002, Ch. 15, § 30.5B). Prior OIG work identified inappropriate payments for chiropractic services. Medicare will not pay for items or services that are not “reasonable and necessary” (SSA § 1862(a)(1)(A)).

Based on these regulations, the OIG is set to review Medicare Part B payments for chiropractic services to determine whether payments were claimed in accordance with Medicare requirements. In one example, a chiropractic practice in Florida was reviewed for two calendar years for potentially inappropriate billing of chiropractic services to Medicare. Out of 21,425 services, totaling $656,051 in Medicare payments, they selected 100 services using a simple random sample which would serve as a representation of their Medicare billing. Of the 100 chiropractic services in their sample, 33 were not allowable: 31 services were medically unnecessary and 2 were not documented. On the basis of those sample results, the OIG estimated the practice received unallowable Medicare payments of at least $169,737 for those two years. This example validates the importance of the development, implementation and enforcement of policies and procedures to ensure thorough understanding of the documentation and medical necessity of billable chiropractic services. Fulcrum currently has documented policies and procedures to support our providers in the understanding of this process. Should you have any questions on the OIG Workplan, CMS regulations and/or Fulcrum’s policy, please feel free to contact Lariza Carlson at l.carlson@fulcrumhealthinc.org .

Education

Reminder to Medicare Providers Regarding Billing Beneficiaries Enrolled In the Qualified Medicare Beneficiaries (QMB) Program

Red FlagThis is an important reminder that federal law prohibits Medicare providers from collecting Medicare Part A and Medicare Part B deductibles, coinsurance or copayments from Original Medicare and Medicare Advantage beneficiaries enrolled in the Qualified Medicare Beneficiaries (QMB) program. The QMB program is a state Medicaid benefit that covers Medicare deductibles, co-insurance and co-payments.

Note: Copayments still apply for Medicare Part D benefits. For those eligible for QMB, this will be copayments at the Low Income Subsidy level.

Medicare providers must accept Medicare payment and Medicaid payment (if any) as payment in full for services given to individuals enrolled in the QMB program. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (S ee Sections 1902(n)(3); 1905(p); 1866(a)(1)(A); 1848(g)(3) of the Social Security Act.)

The QMB program applies to all Medicare providers, both participating and non-participating. Further, providers are obliged to accept assignment on all services to these beneficiaries, even if they would not do so otherwise. Accepting assignment means you agree to accept the Medicare and Medicaid payment as payment in full, regardless of whether Medicaid pays or not.

Providers who are not enrolled as a Medicaid provider are still subject to the QMB program limitations. Because Medicaid won’t pay providers if you aren’t enrolled with Medicaid, Medicare cost-sharing balances must be written off and may not be billed to QMB program enrollees.

At this time, there are a couple of potential ways to identify QMB individuals:

  • If you are a Minnesota Health Care Programs (MHCP) provider, you can directly query the Minnesota Department of Human Services (DHS) MN–ITS system to verify QMB eligibility.
  • You can ask the beneficiary if they are enrolled in the Qualified Medicare Beneficiaries (QMB) program through (MHCP). Medicare beneficiaries eligible for Medicaid QMB programs may have documentation, e.g., QMB eligibility verification letters from DHS they can show providers.

For more information on QMB plans, visit: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/QMB.html

Moving or Retiring? Let us Know!

Address Book IconIt is vital that you report any practice changes to ensure that we have your current address, phone, fax, and email address. Any changes or corrections to your TIN/name combination should be communicated immediately. TheProvider Update tool within ChiroCare Connect offers a quick and electronic means to report changes. Simply select the “Billing Information Update” option within the Provider Update tool.

Please contact our Provider Services team at 877-886-4941 with any questions about submission of updates.

We appreciate your continued partnership!