b'MedicareQ&AMedicare UpdateBy Dr. Richard C. Healy ANJC Medicare ConsultantQ I am non-par with Medicare Part B and non-par with theA Since your patient is covered by a large health group plan, Medicare Advantage plan, may I charge the patient up tothe MA plan is secondary and the LHGP is primary.the limiting charge for the CMT services? If the employer group health plan (the primary payer) has A Medicare cost plan enrollees should never pay more thana copayment of $20 and the Medicare Advantage plan the plan required cost sharingcoinsurance, deductibleshas a copayment of $10 for the service the beneficiary and copays. The MA plan would be responsible for thereceived, the beneficiary cannot be liablepayment up to the limiting charge. to pay more than the plan copayment of $10.Chapter 4, 10.4 of the Medicare Managed Care Manual Chapter 17, 70.2 of the Medicare Managed Care ManualQ Do Medicare Advantage plans have to offer Q How many levels of appeals are there for MA plans?chiropractic services? A Once you receive a denial based on an organizational A As a standard Medicare Part B benefit, manual determination, there are 5 levels of appeals:manipulation of the spine to correct a subluxation 1.Health Plan Reconsiderationmust be made available to enrollees of cost plans. 2.Independent review Entity ReconsiderationChapter 17, 20.2 of the Medicare Managed Care Manual 3. Administrative Law Judge - $170 AICQ Can MA plans impose caps on benefits? (Amount in Controversy) requirement4.Medicare Appeal CouncilA The Medicare cost plan may not impose caps on any5.Federal District Court - $1760 AIC requirementMedicare covered benefit unless original Medicarealso imposes a capChapter 17, 40.1 of the Medicare Managed Care Manual Source:Medicare Managed Care Appeals Flow ChartRichard C. Healy, DC, CCSP, is the treasurer andQ My patient has a MA plan but is also covered by herMedicare consultant for the ANJC. A New Jersey Medicare husbands plan because he is still working. The co-pay forCarrier Advisor Committee delegate and a Certifiedher husbands plan is $20 and her MA plan is $10. WhatChiropractic Insurance Consultant, Dr. Healy is in private do I charge? practice in Dumont.Coding: Chiropractic Services (A52987).from these record collections. The policy page also reminds providers that the AT modifierBeginning late 2019 and continuing now in early 2020, we for acute treatment is also necessary for reimbursementhave heard from many members that they are being asked for under the program.in some cases a large number of patient files.The volume of If you have additional questions on this new policy or anyproviders being asked and the number of patients requested other issues with Horizon NJ Health you can find the providerof each provider have seemed higher than what is normally relations rep for your county under Professional Contractingseen for these reviews.There has been speculation that the and Servicing Staff here:https://www.horizonnjhealth.com/ requests may be for some purpose beyond the stated risk adjustment reviews. contact-us/provider-contacts. I have reached out to Horizon and inquired as to why the Inovalon-Horizon Update volume of requests is so high for these reviews and if the As we have previously reported to you, Inovalon is a companyrecords are being used for any other purpose.Horizon has that is collecting patient records to perform risk adjustmentresponded that any and all record requests from Inovalon are reviews on behalf of Horizon.Risk adjustment reviews arestrictly for risk adjustment reviews and no other purpose.reports required by and provided to the government asFurther, they advise that they began their partnership with dictated by the Patient Protection and Affordable Care ActInovalon late in the year of 2019 and hence need to essentially (PPACA aka Obamacare).All carriers collect data for thesecatch up on records gathered leading to the condensed higher reports and in the years these have been required we have notvolume of record requests.They advise that this should not yet seen a negative consequence for any provider stemmingcontinue to be the practice of the program going forward.www.njchiropractors.com I 15'