Tuesday, August 20, 2019

The Medicare Denial Letter

Topics: Medicare (CMS) denial letter, reimbursement issues in hospital-based practice

The Medicare Denial Letter:

useful for this period of history when Medicare does not cover acupuncture services

Bobbee Vang, LAc, Timothy Suh, DAOM, LAc, and Megan Kingsley Gale, MSAOM, LAc

example of a Medicare Denial Letter
FQHC= federally qualified health centers, more info at the FQHC website
BLUF = bottom line up front. Acronym communication tool
SBAR = situation, background, assessment, recommendation. A team communication tool.

Question(s) for practitioners working in CMS facilities (this includes FQHC) 
When a patient is eligible for Medicare, but Medicare does not cover acupuncture nor acupuncturists as providers, what is the process in billing for care? 
How do you process coverage for a Medicare-qualifying patient in a CMS facility?

Background: The rule in a CMS facility is that Medicare must be billed as primary and then denied in order to bill secondary/co-insurance or supplemental insurance. All other payors we bill under our credentials (as licensed acupuncturists).

Situation (Example): Since Medicare does not cover acupuncture services nor acupuncturists as providers, how does one deal with coverage for a Medicare-qualifying patient in a CMS facility?
In this case, my colleague is dealing with the supplemental insurance denying all reimbursement because they are “awaiting CMS denial”. My colleague’s GY modifiers are now getting denied, too. Prior to Jan. 1st, 2018, they were getting covered/accepted.

Assessment: Yes, you cannot bill. If you bill Medicare, it won’t be considered. So, then it will not be “officially denied”. Treatment must be officially denied by Medicare before you can bill any other insurance or reimbursement program.

BLUF: Ask patient to submit a “request for medical reimbursement”. Since the patient is enrolled in Medicare, the payor must respond to the payment. The response [from CMS/Medicare] is the denial. That response lasts a lifetime and does not need to be renewed. Make a copy of that denial for future billing.

What form is the “request for medical reimbursement”?  
screenshot of form CMS 1490S
8.2019: Form number has changed. The correct form is now CMS 1490S, “request for medical reimbursement”.
Note from the CMS website:
  • “Effective April 1, 2019, only the revised 01-18 version will be accepted for the Form CMS-1490S. the provided link below includes the form and all the applicable instructions. Please read all instructions prior to submitting a claim to Medicare. (1) The Form CMS-1490S is fillable, can be completed online, printed then mailed. (2) Mail the completed form and itemized bills to the correct Medicare Administrative Contractor as indicated on pages 7 through 18 of the instructions.”
  • If you read this and the form is again outdated or you want to make another correction, please note it in the comments below or contact me at the website. Thank you.

“We have kept a denial letter from our early insurance years stating the denial. We keep this letter and send it to the secondary insurance. Most supplement insurance will not cover what Medicare does not deny. The one supplement insurance I have noticed covering acupuncture in my region this year is a Medicare Advantage plan, ‘UnitedHealthcare AARP Medicare Advantage Supplement’. However, a true secondary insurance may have coverage. “–Timothy Suh

Since the CHRONIC Care Act of 2018, some supplement insurance, namely Medicare Advantage plans, do cover acupuncture services. This coverage is highly variable, though. To learn more about this special case coverage in Medicare Advantage and what the CHRONIC Care Act is, go to the related blogpost on this health policy. 

“Personally, I believe Medicare is a fight worth fighting for. [In a few years it is likely] we will have coverage. All the signs point toward it. The only issue is to create the data that backs our medicine in a biopsychosocial model that is accepted by the current system.” -Bobbee Vang

To clarify:
  1. The fill-able form, “request for medical reimbursement” is on the CMS website.
  2. The screenshot at the top of this post is an example of what a Medicare Denial Letter looks like.
  3. Once you have a Medicare Denial Letter for a specific patient, keep it.
  4. This letter is good “forever” or until the law changes.
    • “Medicare is a defined benefit program. For an item or service to be covered by the Medicare program, it must fall within one of the statutorily defined benefit categories outlined in the Social Security Act.”—cms.gov

Related Blogposts

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Saturday, July 27, 2019

Lunchtime Listen Recommendation: The VA Whole Health Program

keywords: Veterans' Health Administration (VHA), U.S. Department of Veterans' Affairs (VA), acupuncturists, the new "whole health" program

The VA Staffing Position for Acupuncturists
Acupuncturists are being hired as a unique staffing position into the U.S. VHA system as part of their whole health programs.  See the "VA Staffing Code" blogpost for more information.

What is the Whole Health program at the VA?
I recommend watching this presentation of Dr. Tracy Gaudet's work with this field-forwarding initiative to learn more. Dr. Gaudet's lecture here is the NIH's Stephen E. Strauss Distinguished Lecture, given November 29th, 2018, "Transforming Veteran's Health Care: The Whole Health System". 

The Academic Collaborative of Integrative Health hosted a webinar series that included a presentation (6.13.2019) on the VA's Whole Health model, "VA's Whole Health System: What can be learned and applied to your practice?" by Kavitha Reddy, MD, and Lauri Phillips, RDN, LD. More information, including how to download slides can be found at the ACIH landing page for this presentation.

For more about the Lunchtime Listen Recommendations series, learn more at this webpage and check out the related YouTube playlist.

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The CHRONIC Care Act: A Health Policy Focused on Addressing Social Determinants of Health

keywords: Centers for Medicaid and Medicare Services (CMS), Medicaid, Medicare, federally qualified health centers (FQHC), Medicare Advantage plans, health policy in the United States, social determinants of health (SDOH), patient-centered medical home (PCMH), accountable care organizations (ACA)

themes: evidence-based health care, addressing social determinants of health (SDOH) to decrease societal health care costs, addressing SDOH to improve individual health outcomes, public health, health policy

Community News on U.S. Health Policy, Research, and Measuring Patient-Centered Outcomes (Metrics): Medicare the CHRONIC Care Act

You know how hit or miss, depending on your region, the Medicare Advantage plans are on covering acupuncture the past couple years? Ever wonder why the Advantage plans have more variability than standard Medicare? This article from JAMA that touches a bit on Medicare Advantage plan flexibility and the 2018 CHRONIC Care Act helped me better understand this and how it has impacted coverage of acupuncture services.

Medicare Advantage programs (not to be confused with regular Medicare) are allowed to be innovative.  In fact, you may have noticed several programs are leading the way on innovation and coverage of integrative health services and other wellness-promoting and function-promoting services.

Some of this innovation is in response to recent federal health policy initiatives to address social determinants of health (SDOH) in patients and patient populations with chronic health conditions.

The following July 2019 study, "Perspectives of Medicare Advantage Plan Representatives on Addressing Social Determinants of Health in Response to the CHRONIC Care Act" looked at how these insurance companies were responding to the Medicare incentive from innovative ideas to limits.

acronym of "CHRONIC" stands for: "Creating High-quality Results and Outcomes Necessary to Improve Chronic care" aka the "CHRONIC Care Act of 2018"

Connection to Integrative Health (IH)
The IH paradigm looks at a person as a garden, as part of a larger system that includes their environment and community. Some Medicare/Medicaid advantage programs have begun covering IH care, including services provided by acupuncturists as related to its large evidence base demonstrating improved health outcomes. Medicare Advantage program patients can receive care at private practice clinics or hospital-based outpatient clinics.

Why This Policy Change and Its Implementation is Important
According to the paper, “The passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act in 2018 allows Medicare Advantage (MA) plans, which enroll more than one-third of Medicare beneficiaries, greater flexibility to address members╩╝ social determinants of health (SDOH) through supplemental benefits.”
“To provide more benefits to address SDOH, MA plans may learn from the experience of other payment models in expanding their service offerings. While, to our knowledge, there is no evidence to date of how MA plans can better address SDOH, flexibility has existed to address SDOH and other patient needs in patient-centered medical homes, 36 accountable care organizations (ACOs),10,37-41 and Medicaid Managed Care. 42-44" [emphasis added]

Challenges these companies have when they are innovating new patient care coverage plans that address social determinants of health

  1. finding strong evidence base for types of clinical care or procedures that show improved patient outcomes 
  2. finding evidence base for cost-effectiveness 
  3. finding partners who can provide these evidence-based services
  4. getting clear guidance from CMS about what is permitted

"In particular, ACOs may face many of the same challenges as MA plans as they begin to take on more capitated risk, i.e., the need for a strong evidence base that addressing SDOH may improve patient outcomes and reduce costs, the ability to find partners who can provide these services, and clear guidance from CMS about what is permitted.39"
"In a 2014 qualitative study (38) of ACO perspectives on SDOH, ACOs, similar to MA plans, were interested in expanding these types of benefits but did not always know how." [emphasis added]
"The Hennepin model, (41) in which a Medicaid Managed Care agency partners with a hospital, a community health center, and the county department of health to better coordinate services, is often seen as a successful example of how organizations can address SDOH through community partnerships."
"The past successes of Medicaid Managed Care in addressing SDOH may be an even more relevant example to MA plans on how an insurer can best address these concerns.(10)” [emphasis added]
Citation: JAMA Netw Open.2019;2(7): e196923. doi:10.1001/jamanetworkopen.2019.6923 

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More Documentation and Coding Resources

keywords: documentation, charting, coding, CPT, E/M, and modifiers, licensed acupuncturist, east Asian medicine practitioners, integrative health

Here are some new resources for reviewing documentation and coding standards in the profession

Documentation and Coding Review Video with Sam Collins, DC of the American Acupuncture Council Information Network, dated May 15th, 2019:

Coding and Use of Modifiers with Evaluation and Management (E/M) codes
  • Article by Sam Collins, DC in the May 2019 edition of Acupuncture Today, volume 20, issue 05.  "The Most Common Modifier for Acupuncture Claims".
  • Summary of content: 
    • An insurance company can deny a claim if you do not code your work to their standard. The common denial issue he discusses in this issue is choosing and using the correct modifier with your E/M code.
    • Types of modifiers he covers in this article include: level 1 modifiers, modifier 25, and modifier 59.  There is also the special case GP modifier that is common in the VHA program that covers acupuncture services by some vetted community providers, "Veterans Choice".
  • source: article by Sam Collins, DC in the May 2019 edition of Acupuncture Today, volume 20, issue 05.  "The Most Common Modifier for Acupuncture Claims". Link to the digital edition of this article. And the webpage version of the article on Acupuncture Today.

Related Blogposts on Documentation include

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Friday, July 26, 2019

Research Thursdays: Oncology

key words:  research literacy, acupuncture and oncology, integrative oncology, sharing related research in the field, research in integrative health; integrative survivorship, oncology and insomnia, program examples

Acupuncture in Oncology

Review of the "Research and Metrics Thursdays" theme from the public Facebook Page and newsletter with focus on Oncology

At the Hospital-practice Handbook Project, we encourage practitioners to cultivate mentor-relationships and practice research literacy

This is a work in progress

Oncology Acupuncture Community News

  • New webpage from the Advocate Aurora Integrative Health program in oncology (program)
  • research--oncology and insomnia.  New paper from Memorial Sloan-Kettering on insomnia in cancer patients
    • Both cognitive behavioral therapy and acupuncture had clinical effectiveness in treating severity of insomnia and had sustained benefits for 20 weeks. It was the first comparative effectiveness study for this clinical research query.
    • Sheila N Garland, Sharon X Xie, Kate DuHamel, Ting Bao, Qing Li, Frances K Barg, Sarah Song, Philip Kantoff, Philip Gehrman, Jun J Mao, Acupuncture Versus Cognitive Behavioral Therapy for Insomnia in Cancer Survivors: A Randomized Clinical Trial, JNCI: Journal of the National Cancer Institute.  https://academic.oup.com/jnci/advance-article-abstract/doi/10.1093/jnci/djz050/5426666
  • Integrative Survivorship programs for life after cancer (program)
    • "Implementing an Integrative Survivorship Program at a Comprehensive Cancer Center: A Multimodal Approach to Life After Cancer”, is a JACM free-access article.  The study: “describes the development of an integrative survivorship program at an urban National Cancer Institute-designated comprehensive cancer center with three closely linked components: a Survivorship Clinic with dedicated staff, a network of Support Services including Wellness, and an Integrative Medicine Program.”
    • Integrative health providers included in this program noted as: nutritionist and acupuncturist. Integrative health programs included: yoga, mindfulness, Healing Touch, and Reiki, and psychosocial oncology.
  • February 2019 National Cancer Institute (NCI) and National Institute of Health (NIH) conference, "The National Cancer Institute NIH Report" by Dr. Jennifer Stone, published in Meridians: Journal of Acupuncture and Oriental Medicine (now the Journal of American Society of Acupuncturists).

Related Community Survey
  • How Do You Define Success in an Integrative Oncology Program? 
    • At this time a large % of acupuncturists working in hospitals are working in oncology programs.  
    • Goal: learn about the current standards and metrics for integrative oncology programs, focus on the work of licensed acupuncturists
    • How will this info be used? 
      • Continue discussion in the community about the following topics: using metrics in clinical care, finding relevant metrics for your work, how integrative oncology programs are being set up, maintained, and grown
      • when enough information, I will publish a blogpost summary 
      • follow up interview potential about specific programs for those interested in participating, part of the "issues in hospital practice" community webinar/interview series.  Go to this post for more about this special Project series.  

Related Interviews
coming soon...

Related Blogposts

More resources on Integrative Oncology Recommended by the Community

For more on the topic of research
  • follow the tag/label in this blog for "research literacy"

Monthly research summary blogposts

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Saturday, July 6, 2019

Basics of Being an Employee in a Healthcare System: Focus on Performance Management, a Wisdom-Share Series with Sondra Abanto, MBA

keywords and phrases: hospital employee, being an employee, basics of being a health care professional in a U.S. health care system, clinician employee, employee acupuncturist, integrative health employee, basics of performance management for the professional health care employee; interview series, special topic; milspouses Megan and Sondra share wisdom for the integrative health community :)

Wisdom-Share Interview Series with Sondra Abanto, MBA


updated July 2019
This interview series is coming to you from the corner of Courage and Commitment.  After 5 years of military PCS moves, our (Sondra and Megan's) worlds are overlapping again.  So, let's take advantage of it!

This is a relaxed interview series where Megan interviews Sondra about the basics of what to expect when you are an employee in a medium to large organization, with emphasis on health care organizations and asides about working as an integrative health care clinician within the system.  We talk about what to expect in an ideal situation from parameters to resources.

This is a series of interviews we (Megan and Sondra) recorded in winter and spring 2019 where Sondra covers the following topics related to performance management:

  1. employee orientation process basics (onboarding)
  2. performance plans
  3. mentorship
  4. team communication
  5. career path mapping

This series is intended for the acupuncturist or related integrative health care professional working (or interested in working) in hospital-based practice in the U.S., whether the civilian sector or the federal sector of employment.  However, we go over basics that apply to any health care professional employee in the system.

Sondra Abanto, MBA, has significant experience in both civilian and federal sectors on program and performance management (metrics) who has also trained as an MSA (acupuncture) student.

As of summer 2019, the sessions have finished recording and will be going to the video editor. If you are interested in this interview series, sign up on the landing page email list and you'll be notified when the recordings and related materials are published. Go here to sign up.

We are still looking for sponsors for this series, if you or your organization is interested in sponsoring this series (partially or fully), please let us know via the website contact page very soon as the finished videos will start going to the video editor in summer 2019.

Sponsorship would help with the following:  creating recordings, editing recordings, creating transcripts, creating pdfs related to each session.

You can also provide feedback on the series and what you would like to see more of at the website contact page.

I am looking forward to hearing from you!
Megan Kingsley Gale, MSAOM

Founder and Facilitator of The Hospital practice Handbook Project for Acupuncturists and their Hospital Sponsors


Monday, June 24, 2019

June Community Survey and Opportunity to Submit Qs

keywords: research, community survey, conferences, electronic health record (EHR), hospital-based practice
Earlier in June, I sent out a community survey to learn about our community's hospital-based electronic health record use experience.

Goal: understand which EHR systems the community is using and any feedback about how that is working well or what the challenges are.
How will this info be used?
If there is a good response rate, the de-identified data will be used in a blogpost summary. If there are common concerns or issues reported, that will be added to our outline of issues to address in the future "Issues in Hospital Practice" community webinar/interview series. For more about this special Project series, see the post on the webinar series project.

This week I will be attending the 2019 Society of Acupuncture Research (SAR) conference in Vermont. This is an in-person conference. Several colleagues told me they are unable to attend, so I offered to submit their questions to the panels in the hospital-based practice pre-conference (Thursday) sessions. If you work in hospital-based practice as an acupuncturist or as a manager or department head of a program that includes acupuncturists as clinicians, you may send me your questions and I will submit them to the panels this week. However, for timing, you must get your queries in to me by Wednesday, 6/26/2019.  Since I am traveling, the best way for me to have all the queries together is to use the survey form. So, I just added the SAR query option as the last section to the June community survey.

Learn more about the topics, presentations, and panels to inform the queries you want to send me on the related subjects at this conference link.  ­čśä

More about the Pre-Conference Agenda
“Research is formalized curiosity. It is poking and prying with a purpose. ” -Zora Neale Hurston
quoted from conference agenda page:

Pre-Conference Special Interest Group 2 – Acupuncture in a Health Care System: Research Opportunities and Obstacles  This workshop is for acupuncturists who work in a health system or hospital setting in order to provide a space for collaboration, networking and strategic initiative. Each two-hour segment consists of two sessions, as follows.
  • The Risks and Rewards of Using the Electronic Health Record (EHR) for Research
    • Jeff Dusek, PhD, Director of Research, Connor Integrative Health Network, University Hospitals, Cleveland, OH
    • One of the major transformations in healthcare has been the growth and reliance on the electronic health record (EHR) in healthcare.  The EHR is truly ubiquitous in 21st century hospitals. 
    • The goal of this talk will be to provide some helpful hints and education to assist researchers who are considering requesting data from the EHR treasure trove.  The talk will review both risks and rewards of using data from the EHR for research and provide some potential ways to be an active participant in the EHR build at their own institutions.
  • Developing an EHR Template across Systems for Clinical Care and Research
    • Helen Ye, MS, LAc., UCSF Osher Center for Integrative Medicine
    • As increasing numbers of acupuncturists work in institutional settings, electronic health records (EHR) are a fundamental aspect of documenting patient care; however multiple EHR systems are used across settings and institutions, and EHR training in acupuncture educational institutions is minimal. 
    • Documentation practices need consistency for patient care purposes, research, and to accurately reflect the work, skills and training of acupuncture and Chinese medicine providers in Western medicine environments.
    • In addition, the tremendous potential for “data mining” through EHR systems is severely constrained without common templates that allow for consistent data gathering of patient care.  
    • The University of California at San Francisco’s (UCSF) Osher Center’s Chinese medicine team has worked to develop consistent documentation practices with templates and shortcuts for frequently used content and tools within EPIC, one of the country’s largest and commonly used EHR systems in large institutions, to be published in the Journal of Alternative and Complementary Medicine. 
    • If researchers and practitioners are able to develop a consensus template(s) across institutions, data gathering for multiple research projects can be leveraged to a much larger degree; patient outcomes and best practices can be better monitored and identified, providing further support for the profession, as well as education and training programs and policy decisions.
    • This session will allow the opportunity to explore these possibilities through the presentation of UCSF’s work on their EHR, and a panel discussion to provide input on moving this fundamental shift in paradigm for all acupuncture practitioners and researchers in institutions across regions. 
  • Response Panel time
Afternoon sessions
  • Integration of Acupuncture into Health Systems: Where are the tipping points?
    • Arya Nielsen, PhD, LAc., Icahn School of Medicine at Mount Sinai, Department of Family Medicine & Community Health
    • Integration of acupuncture into health systems is not a uniform process.  At each institution, choices are made as to which inpatient or outpatient units will offer the service, which patients are eligible, and who makes the decision to refer.  These decisions are the inflection points determining how quickly integration proceeds, and several factors can tip them in one direction or another.  The acupuncture evidence base is one key factor; others include perceived benefits of acupuncture (by patients or care providers), cost data, and the potential for acupuncture to help with specific challenges already identified — from the need to provide smoking cessation services to the current opioid epidemic, or the paucity of treatment options for conditions such as pain, threatened miscarriage and irritable bowel syndrome. 
    • This session, intended for acupuncturists working in health care systems as well as researchers, will explore these three factors in practical terms.  
  • Panel discussion with Arya Nielsen and Claudia Citkovitz 
    • the panel will discuss areas of systems-based practice where acupuncture’s clinical impact appears to be strong despite lack of research to date, and areas where acupuncture may be useful in addressing patient care problems previously identified by the institution.
  • Integration of Acupuncture at the Veteran’s Administration
    • Juli Olson, Doctor of Chiropractic, Masters of Acupuncture and OM, Diplomate in Acupuncture (NCCAOM), Licensed Acupuncturist
    • Justin Heesakker, Doctor of Acupuncture and OM, Diplomate in Oriental Medicine (NCCAOM), Licensed Acupuncturist
    • The purpose of this talk is to share what is happening in the Veteran’s Administration, regarding the integration of acupuncture in the largest healthcare system in the United States.
    • We will talk about challenges and opportunities of rolling out acupuncture on such a large scale across a large area. This is a very exciting time where a large group of veterans now have access to acupuncture care that previously would have had to pay out of pocket, and new possibilities are opening for large-scale acupuncture research.
    • In 2017, a list of approved evidence-based Complementary Integrative Health (CIH) methods of care were added to the Veteran’s Benefits Package. Included are acupuncture, biofeedback, clinical hypnosis, guided imagery, massage, meditation, tai chi/qi gong and yoga. In 2018, the Veteran’s Administration created a Qualification Standard for Licensed Acupuncturists so they may be hired as full time federal employees. Developing policies and offering best practices allows for greater acceptance of the profession and quick integration.
    • The growth of acupuncture is expected to continue at a quick pace. In order to meet the immediate demand for acupuncture services, the VA has widely trained non-acupuncture providers in Battlefield Acupuncture (BFA). Policies have been developed to improve access, including allowing multiple disciplines to train and provide BFA, eliminating written consent for auricular acupuncture and utilizing note templates in the EHR to collect research data specific to BFA.
    • In preparation for the decision to add acupuncture to the Veteran’s Benefit Package, the VA underwent a systematic review of the literature culminating in the Acupuncture Evidence Maps published by the VA’s own Health Services Research and Development branch in 2014.  In collaboration with the Department of Defense acupuncture has been included in several VA/DoD Clinical Practice Guidelines (CPG). 
    • As acupuncture becomes more widely available, the ability to measure both subjective and biometric outcomes, conducting clinical research on a large scale will be possible through the electronic health and designed notes. Additionally, capturing utilization & cost data provides an opportunity to examine cost effectiveness for acupuncture, CIH and the Whole Health model.  The Whole Health framework is a patient-centered care model that emphasizes a patient’s own goals for their health with resources and skill building to help them achieve those goals.

Looking forward to hearing from you all in the survey! Stay tuned to the newsletter for post-conference notes.  :) 

You can buy me a coffee while I am traveling this month and while I am at the conference, whether a shot of espresso, a cup of cocoa,
or a carafe of coffee while I meet with other hospital-based colleagues at the conference.