Tuesday, August 20, 2019

The Medicare Denial Letter

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

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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 which is 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 the 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 the 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 on 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 blog post 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

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