How to Use and Implement the Medicare Brochure
Before implementing any of these suggestions, be sure to either imprint the back side of the brochure with a high quality rubber stamp or laser print your practice information onto a clear adhesive label and apply on the back side in the space provided!
Here's how to get the maximum effect when using the Patient Media Medicare Brochure. Use these guidelines to create effective scripting for your practice. (Because of the way this brochure is used, it's probably not a brochure that you'd place in your brochure rack.)
Here are eight ways to use it:
Before the Consultation
When a new Medicare patient returns their completed intake paperwork to the front desk, the CA says:
"Thank you Mrs. Jones. I'll get everything ready for Dr. Smith. Since Medicare handles chiropractic care differently than medical treatment, this explains what you'll want to know before seeing Dr. Smith. It should be just a few minutes."
Give the new patient enough time to read the brochure. Use this time to ensure that the intake form is properly completed. By the time the doctor walks into the room to begin the history and consultation, the patient should have enough time to read the Medicare brochure.
Many practices find it helpful to highlight a key sentence or paragraph to add emphasis.
During the Consultation
Often during the new patient pre-care interview, the subject of finances will arise. Explaining a Medicare patient's initial financial responsibility should occur before any CPT coded, billable service begins. It might sound something like this:
"From what you've shared with me, I think you're an excellent candidate for chiropractic care. Next, we need to conduct a thorough evaluation, including an examination (and possible x-rays), to locate the underlying cause of your problem. Once that is complete, I can review the findings and make specific recommendations.
"I understand that you are covered by Medicare. You've reviewed the brochure that Sally gave you? Great. We expect there to be some coverage for your treatment in the office. However, moving forward with an examination and evaluation will incur costs that, as you saw, are not covered by Medicare. We offer a variety of options to make this affordable for you. Shall we get started?"
Some of your options are:
- If you are a member of a Discount Medical Plan Organization, such as ChiroHealthUSA, PCD, or others, you are entitled to offer this Medicare patient a network based cash discount on these initial, non-covered charges. Share your discounted fee with the patient at this time.
- The government has indicated that you are able to offer a 5-15% "time of service" discount, off of your actual fee schedule, to Medicare patients, when they pay at the time of service.
- If you have a valid Financial Hardship Policy, you can qualify this patient for hardship discounts with their application and request for assistance, along with properly verified financial hardship.
- You may wish to extend a payment plan to the patient to cover some of the charges today, and make further payments on the balance due.
If you prefer, you may wish to allow a team member to come in to answer additional financial questions. The goal is to make sure the patient understands that continuing with the exam and possible X-rays will incur out of pocket costs to them.
During the Report of Findings
Refer to a copy of the Medicare brochure you previously presented to the patient as you explain your diagnosis and recommended treatment plan. Help them understand Medicare's concept of what is considered "medically necessary" (and thus reimbursable), and what services Medicare expects the patient to pay for. You might say:
"Remember this? (Referring to the brochure) Medicare is very specific about what portion of your care they will consider for payment. Remember where they explained here, (pointing and reading under the heading "Functional Improvement")? 'Instead of judging your progress simply by how you feel, Medicare wants to see improved function. That means a restored ability to turn, bend, walk, sleep, and generally perform your daily activities. Once improvement stops, Medicare coverage stops. That's because they consider further care to be maintenance care and expect you to self-pay.'
"My initial recommendations will include both what we expect Medicare to pay, and what may be your responsibility (if applicable). Sally will be here in a moment to explain all the details. Before I go, do you have any clinical questions for me?"
Use the brochure to further explain things such as your participation in Medicare, how excluded services work, and other important aspects of how Medicare works in your practice.
Use the Patient Media Medicare Worksheet to show how your first-visit fees are computed.
During the Financial Report of Findings
When explaining a Medicare patient's estimated financial responsibility, especially non-covered Medicare services, it's helpful to have a copy of Medicare brochure handy for reference. If the patient has joined a Discount Medical Plan Organization (DMPO) like ChiroHealthUSA on the first visit, you will calculate the non-covered services estimate using that discounted fee schedule. If not, you are free to reduce your actual fee up to a 15%.
"Dr. Smith told us that your initial treatment will require between 12-18 visits, which will include some services that Medicare expects you to cover. (Pointing to the brochure section on Excluded Services) 'We only recommend the care that is clinically appropriate. That might include other procedures such as massage, traction and other therapies. Medicare does not pay for these, nor do they pay for adjustments to your wrist, ankle or other extremity. Sometimes these procedures may be covered by any supplemental insurance you may have.' Since you wisely joined ChiroHealthUSA on your initial visit, I've been able to calculate your estimated financial responsibility for these services using that discounted fee schedule."
Continue with your normal procedure for explaining the patient's estimated financial responsibility and give them another copy of the brochure if they want to study it further.
During Routine Visits
There may be occasions when the subject of Medicare comes up. Or you may need to explain the Medicare implications of additional services that may be required. Or, the patient may be approaching the end of the medically necessary portion of their care. Refer to the Maintenance Care section:
"Mary, looks like you're responding beautifully to chiropractic care. Today you reported very little pain and your ability to get back out onto the golf course has almost fully returned. Remember, Medicare will continue to cover these visits up to the time when I believe your function is unlikely to improve further. We'll continue on our current treatment plan and at your re-evaluation on (insert day) we'll be able to tell exactly where you are in the timeline. This is great news! You're doing very well."
Keeping a Medicare patient informed along the way about coverage that may be of concern to them is made easy with the references in this brochure. Keep some in the treatment rooms to use for this purpose.
At the Re-Evaluation
Periodic re-evaluations are especially important with a Medicare patient. Certain levels of evaluation are included on a daily basis in the value of your Chiropractic Manipulative Treatment (CMT) code. Periodically, you're expected to analyze and compare findings, Outcome Assessment scores, and measurement of the patient's function. These re-evaluations are critical to documenting medical necessity. Of course, this formal re-evaluation, billed as an Established Patient Evaluation and Management (E/M) code (99212-99215) must be charged to the patient as an excluded service. If the need arises to explain the cost, it could be done by again referring to the Medicare brochure:
(Pointing to the Excluded Services or Examination section) "Mrs. Jones, this re-evaluation is required by Medicare to substantiate the care that they will cover. Remember, they expect you to cover these costs. The estimated fee for today's exam, since you're a ChiroHealthUSA member, is $XX, as we have elected to cap our exams at that fee, regardless of the level of service". Or, "The estimated fee for today's exam is $YY." (Referencing your full fee).
At Discharge from Active Treatment
By using these recommended communication procedures it won't be a surprise when the patient is ready for discharge from active treatment. Whether at your discharge exam, or during a routine visit, should the need arise, refer to the brochure to explain the value and purpose of maintenance care. Remind them that while Medicare doesn't cover maintenance care, they may choose to self-pay and receive the benefits of ongoing care.
Be sure that all official Advance Beneficiary Notice activities are handled correctly when maintenance begins, but for now, you can educate the patient by pointing to the maintenance care section of the brochure:
"The great news, Mrs. Jones, is that we've reached maximum functional improvement with your (insert condition) and you've responded so beautifully to care. I'm going to discharge you from active treatment at this time, meaning that we will notify Medicare that this episode of your care has ended today. If you have any flare ups, new conditions, or decrease in your stable function, of course Medicare will likely contribute to your financial responsibility under those circumstances. This brochure explains what Medicare considers to be maintenance care here."
Every chiropractor has his or her own philosophy of maintenance care, its necessity, its frequency and even its name. Explain to each patient that Medicare will not pay for the visits that do not show functional deficit, but are encouraged to continue at their own expense to protect the investment they've already made.
While in Maintenance Care
It's often difficult for a Medicare patient to understand why, when they are showing up in your practice with stiffness or soreness, but without significant functional deficits, Medicare won't cover their visit. There may be times when you must reiterate to the patient how the Medicare coverage works. After your brief evaluation of the patient on a maintenance visit, if you do not believe the visit to be billable as medically necessary, you can refer back to the content of the brochure to explain the concept of what is and isn't covered. If the patient remains confused at the lack of coverage, you may need to reference it, in particular, the paragraph about Medical Necessity that clearly explains what the chiropractor is held accountable for. You might explain this by saying something like:
"Mrs. Jones, although you're reporting here today with some pain in your upper back as before, you've told me that you're still able to do all the things you normally do. You're still walking a mile after dinner, playing golf three times a week, and you're sitting, sleeping and lifting with no difficulty. Medicare expects you to pick up the cost of these types of visits that don't hold the promise of making functional improvement"
Be sure that your patient has signed the necessary Advance Beneficiary Notice of Noncoverage (ABN) for any adjustments (CMT) that are deemed maintenance care. Of course, once the ABN has been signed for a period of maintenance care, that ABN is good for one year, or until the patient goes back into an active episode of covered care, whichever comes first.