b'CODING Update ComplianceLEGAL NUTRITIONCouncilANJC Leadership LEGAL EASE NUTRITION REHAB Council Executive Directors Update LEGAL Q&A CHIROASSISTINSURANCE Update INSURANCE Update Legislative UpdateTECHNIQUE CouncilQ What are the documentation requirements forMedicareQ&AMedicare UpdateMA plans? OUR HEALTHA Medical necessity documentation that is required by an MA plan will vary depending on whether there is By Dr. Richard C. Healyan existing National Coverage Determination, Local ANJC Medicare Consultant Coverage Determination, or coverage guidance from CMS that the MA plan must follow, or in the case that there was no national or local policies, the Q If I am out of network with a Medicare AdvantageMA plan makes its own coverage determination for a product or service.Plan, for example Horizon or Aetna, what is the reimbursement from these plans? It comes down to 3 scenarios:A Medicare coordinated care plans participating in1)If there is a National Coverage Determinationthe Medicare Advantage (MA) program, suchor Local Coverage Determination, the MA plan as Health Maintenance Organizations (HMOs)would adopt those coverage rules.and Preferred Provider Organizations (PPOs), aregenerally required to reimburse non-contracting2)If there is no NCD or LCD, the MA plan may providers at least the original Medicare (Fee-for-Ser- adopt the coverage policies of other MA plans in vice or FFS) rate for Medicare-covered servicesits service area.provided to the MA plans enrollees.3)They may adopt their own coverage rules.So, if you are participating with traditional MedicareIn New Jersey, we have a Local Coverage and OON with the MA plan, you would be reim- Determination, so the recommendation would be bursed up to the par fee schedule under traditionalto follow traditional Medicares documentation Medicare. requirementsIf you are non-par with traditional Medicare, you would be reimbursed up to Medicares limitingQ With traditional Medicare, there is no tiering of charge for that covered service. providers. Is it permissible for MA plans to tier?What is the reimbursement rate if I am par with A Yes. MA plans may choose to tier the cost-sharing Q the MA plan? for contracted providers as an incentive to encourage enrollees to seek care from providers the A Par providers with the Medicare Advantage Plan areplan identifies based on efficiency and quality data. obligated to accept the MA plans fee schedule. The tiered cost-sharing must satisfy the following standards:Q I am non-par with the MA Plan and non-par withThe plan fully discloses tiered cost-sharing traditional Medicare, but when I received my ERA it stated the patient was only responsible for theiramounts and requirements to enrollees and plan co-pay of $10.00. Why is that? providers;The services at each tier of cost-sharing areA When a MA Plan patient who is enrolled in aavailable to all enrollees;PPO-type plan uses a non-par (non-contracted) provider, that enrollee is only responsible forEnrollees may not be limited to obtainingtheir cost sharing. (* HMO plans generally requireservices from providers/suppliers assigned to a enrollees to use in network providers) particular tier; andThis means if they have a $10.00 co-pay or theyAll enrollees are charged the same amount forhave a co-insurance of 20%, that is all they arethe same service provided by the same provider.responsible to pay. However, the MA plan is legally responsible to pay the additional money to theRichard C. Healy, DC, CCSP, is the treasurer and Medicare provider. consultant for the ANJC. A New Jersey Medicare CarrierFor example, as mentioned if you are non-par withAdvisory Committee delegate and a Certified Chiropractic Medicare and the MA plan, you may bill up to theInsurance Consultant, Dr. Healy is a graduate of New York limiting charge for the covered service. Lets say theChiropractic College and has been in private practice inlimiting charge is $48.39 for a 98941 code. PatientDumont for more than 35 years. has a co-pay of $10.00. You would collect $10.00 from the patient and the MA plan should reimburse you $38.39.This is different than traditional Medicare, where the patient is responsible to pay the difference from the allowed charge to the limiting charge.www.njchiropractors.com I 19'