Empowering Women in Chiropractic – ABN Form-Time is Running Out – Yvette Noel of KMC University

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Good afternoon. Thank you for allowing me to join you today. I thank you to ChiroSecure for inviting me to speak to you. Once again, spoke to you about the 14th of last month, where we were talking about enrolling with Medicare and what that means. Box 24 J raising your hand. But today as promised, we’re going to talk about that ABN form. The new one was released, and we’re going to get right into that topic today. So let’s go ahead. Let’s get those slides going so we can get you guys moving with the learning you came here for today. Again, we’re going to cover that new ABN for Medicare. We had waited for quite a while and once Medicare had released it, we all kind of had to sit there and decipher, what did they say? And this may and the Medicare ABN form instruction this time.

And we realized there were some changes that took place. And that’s why I wanted to pause just to see what they would say, but there is still some time out with the jury. So you’ll get what I’m saying with that statement in just a moment. So like I said, what we’re going to cover is we’re going to learn some of the differences between what is on the voluntary for what constitutes voluntary and mandatory ABN, what that means. Some options you have around that voluntary. We’ll also talk about when to utilize the ABN form. We’re going to talk about the deadlines for implementation of the new form. And then we’re going to discover changes with the QMB patients. So a lot to cover in this short little time together. So let’s stick on our seatbelts and let’s go for this ride. Uh, just so we can start off right off the bat.

Everybody’s wanting to know when do I have to have it in the practice, or maybe this is the first time you’re hearing about it. But Medicare did issue that new ABN form. As you recall, we had done at the very bottom of the form expiration three 20, 20 it long went by and we had to wait all the way until towards the end of June 1st part of July, to see that they actually had finally gotten it together and said, we have one for you. Here’s your new deadline. So we didn’t get one before the expiration date, but we now have an expiration date of implementing this new form. And as you see here on the screen, that is August 31st of this year, it’s going to last us for a few years. You’ll see that with the new expiration date that you’ll notice here in a few minutes, but let’s just ride this out together and see what we can discover.

Now, first, a disclaimer, Medicare’s ABN form instructions were better this time, but they weren’t as concise as they needed to be. So KMC university, we went to Medicare, we asked one question and they answered it right away, feeling hopeful that we would get an immediate response on our extra questions that we have, which I think are about six of them. Now, just to get clarity and I get an email that I’ll show you right towards the very end of this presentation, where they say, uh, we need some more time. We’ve got to meet together, let us get back to you. So we are waiting and that jury is still out on some of those final pieces of that ABN form instruction that just aren’t clear crystal clear force at this point. So last time we met, we talked about being enrolled or not enrolled. That was the question.

If you remember, and there were a lot of other either, or that we still had to discuss. So like I said, we crossed that one off the list and we’re going to work on a few more of them today. Let’s just see how far we can go. I can promise you, we’re going to talk about the mandatory and voluntary ABN what’s covered. What’s not covered. We’ll hit the highlights of some of these other things that you’ll discover as we go along. So Medicare States, there are several, probably the top five issues with ABN forms and they notice this as they are going through and processing, or just how, when they ask for records, they want to see the ABN form what’s wrong with them. Well, they don’t have a patient’s signature. We’ll talk about that. Cause the mandatory ABN has to have the patient’s signature.

What about box F? We have no cost estimates in there. We’ll say all Medicare doesn’t cover this. This is why. And we leave the cost blank. They have, this is an advanced notice. They need to know what to expect. They’re signed on every single visit. You can save your trees. You do not have to have one signed on every single visit. Medicare even says that they have a Medicare learning network publication that States that it’s misinformation. When you feel that you have to have one signed it, every single visit, maybe it’s missing the notifier information at the top. Maybe you simply forgot to put your practice name and specify all that out and get all the patient name and any identifying information there that can make it invalid. Or the one we see all the time at KMC university is that we have a mix of the covered.

We’ll explain this in a minute. And the non, the statutory excluded services on the exact same ABN. You may not. Can’t have everything from the first visit on my ABN form. You cannot, there is one that’s called a mandatory and that has our covered services. And then there’s one that’s called a voluntary that has our statutorily excluded services. And we’ll dig a little bit further into what covered is and what statutorily excluded is as we go along. So again, is it a yes or a no, let’s unravel it, but we’ll see here that we have covered services on one side. Yes. The cover. And then we have excluded services on the other. No they don’t. And these two, actually I can change the wording just a little bit to make it more clear covered. It’s going to change and excluded. Let’s watch covers in the blue and excluded in the green.

Whoa, we have mandatory ABN on the covered side and we have voluntary ABN on the statutory excluded side, right there alone tells you they shouldn’t be on the same form, but let’s keep digging. So mandatory. Mandatory means it’s required. You can’t squeak by, without it remember from last time, it’s not a work around to being enrolled, but you can’t squeak by and it’s only for spinal CMT services. Well, let’s think about it. When we think about how Medicare and chiropractic works together, we know that Medicare only covers three services. The spinal CMT, the one to two region, the three to four and the five (989) 409-8941 and nine eight nine four two. That’s it it’s covered. The question is, is it payable by Medicare? That’s where you have the in between active care and maintenance care. And it’s over here when maintenance starts that we have to get the ABN form sign.

It’s mandatory. We have to do this. Okay. And there’s usually only a one or two reasons why that we have to include it. And yeah, again, it’s not that opt out that we talked about back in July voluntary means it’s not required. You volunteer to do something. Nobody made you do it. You’re just stepping up to do it on your own. It’s for all those statutorily excluded services, the one Medicare never covers let’s think about that. That’s your therapies. You’re, x-rays your exams, your nutritional products, your nutritional counseling, all of those things that Medicare never covers would go on a voluntary ABN form. And again, they’re two separate things. It’s just good business practice to make sure your Medicare patient knows in advance about the exams and all those other services. Medicare would never cover, but it’s not required as it is with the ABN form for the mandatory spinal CMT services.

And we actually at KMC university recommend when you’re doing it for voluntary purposes, that you don’t even use the Medicare ABN form. I know the air just sucked out of your body and we’re going to have a discussion. And you probably are saying, I’ve got talk to this lady. She doesn’t understand. We actually do. And like I said, last time, anytime that we give information from KMC university, we always make sure to have reference. It’s not just from our understanding. It’s actually pinpoint reference straight from Medicare themselves. You can see here that one of those situations straight from Medicare, they say these structions should only be used when the ABN is used to transport transfer potential financial liability to the beneficiary and not in there. It is voluntary instances. Just like I said on that last one. It doesn’t have to be for voluntary. It’s really not for that.

You can, but my goodness, the rules you have to follow and jump through and you have to include another modifier. And Lord knows we have enough of those and then more information on dual eligibility, but a fairy Sherry’s maybe found that’s that QMB. And as you recall, we were going to talk a little bit more about that today because that’s a big, big change with the new ABN form layout. So let’s talk about it a little bit further covered, not covered a statutorily excluded event helped me. So when we see here in that first block, we talk about the covered and payable member. I said that word payable, that is the act of treatment, a T modifier worthy. I can prove it. I have the documentation and the patient’s still having some dysfunction. I’m still making improvement. We’re still on track with our goals. Everything’s laid out beautifully.

According to what Medicare says, you have to have you stick an 80. It’s covered it’s payable. Now we have covered, this is maintenance. Medicare specifically says when we have, I kind of say, stalemated, the patients reached the best they can be. They’re not going to have the same goals as an act of 20 year old, um, or someone who’s never had a problem in their life. They may be osteoporotic. They may be having some degeneration. They have some, sometimes some advanced diseases or dysfunctions that will prevent them from being at this patient will have zero pain. This patient will have full range of motion. It may never happen, but there’s a point that they’re no longer making the progress no more would you expect them to get better, but they’ve maxed on you. They’re going to maintenance. There’s more art to it, but you kind of get what I’m saying.

There that’s a covered service because spinal CMT is, but it’s not payable. That’s maintenance. That’s why this is mandatory is because sometimes Medicare will cover it. And then there’s certain conditions where Medicare will not cover it. That’s why it’s mandatory to let that patient know when there is a service that Medicare would otherwise cover. Now, when we look down below, we’ll see some of those that were statutorily excluded. I mentioned the ABN is not required. We saw that on the previous screen. And then we look at the actual services that that may include. We have an extremity CMT. We have x-rays products, supplies, therapies, exams, in any alternative treatment protocols. Medicare says, you can do them. I’m not paying. And also here’s just the key element. Yeah. Better charge the Medicare patient for that surface because simply thinking they can’t afford it is not defensible.

Should that be evaluated? So when we’re talking about mandatory submission, that voluntary, we can kind of take our modifiers that we know and split them right down in the middle. Some are only for those covered services. And then the others are for those services that are never covered. Let’s do that again. Some are for those mandatory submissions, that mandatory AAV and when it comes into play and some are for the voluntary. So again, when we are submitting for those spinal CMT services, it’s either active member are either or it’s either active or maintenance. It’s either a T or hopefully you got the ABN form and it’s GA if you didn’t get the ABN form, it’s that third one down in the list. It’s Jeezy. Geez. Why did I forget to get that ABN form? Now I can’t collect from anybody. Then we split that difference.

We go down to the voluntary. Remember we said those exams, therapies, x-rays all that nice stuff. And every one of those that Medicare never, ever, ever covers, no matter what you do gets a G. Why G why Medicare did you not cover that? And then from there, we may have other modifiers that come into play. So let’s say we’re doing nine, seven codes are that G zero two eight three. We have to add that GP got PT. They have to have a pairing of modifiers on the physical medicine services. And there’s that one, right? Smack dab in the middle that I told you about. If you want to use the voluntary ABN form, that’s the third one. That’s why we say don’t even fool with it, but don’t worry if we’re going to cover that a little bit more as we go along. So first we’re going to talk about the covered services.

ABNs are mandatory for the spinal CMT services. When they are for maintenance, we would never hit the patient. When they first come to our office with an ABN, with a spinal CMT service listed on it. Unless for some reason you have somebody coming in that starts as a maintenance patient. Typically that’s not what we have. So if your ABN that you’re issuing from the very first visit has spinal CMT service on it. It’s wrong. You need to correct that and just pay really close attention here today, to what we’re discussing here in these slides. When that spinal CMT services crosses over to being maintenance, you do have to provide the patient, the ABN. Then that’s when it comes out, it’s conditional. It stays hidden. Medicare patient goes along, making their track up and they start to stalemate. They just start bouncing around up here. Same predictable behavior may be coming less often.

That point where they get a parents, start get that AB and out, switch your 80, turn it off and bring on your GA modifier. You’re going to see this in a minute on my screen, how it kind of ebbs and flows that AB and form once it’s signed can last you up to one year. If it’s not interrupted in segments somewhere along the way, where that patient goes back into active care. So they started maintenance here and they started a new active care here. Guess what happened to this ABN form? It got smushed right in the middle. It’s no longer active the minute they go back in, but let’s say they want that full year and it didn’t get interrupted four year, get a new one. When they come out of active again and start another stretch, get a new one. And those again can remain active for up to one year, as long as they are not interrupted.

So Medicare gives us some additional guidance here. You can see in bullet 0.2, this is another just reiterating why you have to use them for the mandatory Medicare would usually cover it. It’s just under this circumstance. They will not. And they wouldn’t consider it medically reasonable and necessary this again, like I said, we’re going to come to you with proof before we say it. This is straight out of a Medicare guidance and the horse’s mouth. This is something that we use here at KMC university for our clients. And this is kind of a way for you to ask yourself, do they need, do they not need an ABN? Well, number one is a spinal CMT service. That’s the first question. And then from there you just kind of go through the algorithms of branching off and do I need one here? Do I need one there?

What do I need to do? This is just a great resource. And you can see that we’ve got a lot of the information built in for a lot of the new situations we’re going through with the QMB and non-par and those types of things. So the DC is the one who decides, do not expect your front desk person to pull it out of their hat. When this patient is going to be maintenance, unless it came from you as a clinical decision, it’s got an exit, your mouth exit. You’re thinking discharging that patient for that act phase of care and only, you know, and when you sit back, doctor and you ask yourself, is this maintenance or is it not? Do you have a subluxation present that is capable of causing a significant enough neuromuscular skeletal condition? And does that patient have documented loss of function that can be improved?

If the answer is no. In this circumstance for Medicare coverage requirements, medical necessity cannot be established and right there is your cue. I need an ABN form. Hey, Sally, at the front desk, grab me one. Or maybe you take a moment to assess, and you’ve got some papers over here on the wall and you go, okay, this one will not be mrs. Smith. I just needed to and have your conversation. Medicare does not cover have that conversation with that patient, switch them over to maintenance and put a pin, just put a pin in what just happened. And then you’ll have your ABN form for this phase of maintenance care. So I told you, we’d talk about that ebb and flow. Someone may go on active care and then they’ll go off. So they’ll start active care. So that’s a new box, 14, and then they’ll jump up and they’ll make all of their advances that they need to meet and will eventually hit the place where we’re going to have to do a new ABN and a GA.

When they go over to maintenance, switch ATF GA on ABN out, then we may have a situation where that patient comes back again within that one year period, and they have a new condition. So now we have a new box, 14 that ABN just got smushed back there in that gray area that you see right here, that squished here, it can’t come out anymore. It got interrupted. You’re going to use the AAT modifier again, and then that patient’s going to eventually cycle off of this space. And then we’ll come back and we’re going to have to get a new ABN signed and that gas is going to come out again. And then if they go back again, just going through the cycle, squashes it in the gray area, and then we start all over. Or they continue with that gray area of maintenance with the ABN and the GA modifier for a year.

So how does that look? You bet on my ABN form, we’ll notice several things. One, we talked about some of those common errors and that’s up at the very top where we have it highlighted everything that we see highlighted are common mistakes that you will find on an ABN form. Very top is your practice identifying information well, who issued the ABN? It is. Nobody can tell anywhere else on this form that it came from your office unless the notifiers ups up there. So that is one of the five common mistakes of the ABN form. Do keep in mind where it has patient name. You do need to have that written there, and then you have the identifier. Please do not put anything that has their social, anything that identifies them truly from a Phi place. Maybe you could use your practice software. It’s assigned mrs.

Smith, a patient number 1,102, well, 1,102 could go there. We don’t want to put the patient’s, uh, MBI, which is that Medicare beneficiary identifier, nor do we want to put that social security number. So then we skip down to some of these areas where it did say D if you’ve got one of those that just says D all throughout and nothing is written in there, it’s not valid. If you have just blanks where you’re seeing these highlights, it’s not valid. So let’s go D is where all those highlights are, where you see maintenance care. Let’s here’s one of them here. One here, one here, and we have one up here. It is driving from this information that you have here. So chiropractic maintenance care. Remember what are the three that are covered, but sometimes not payable nine eight, nine four zero (989) 419-8942. Now tell us why Medicare patient doesn’t understand.

It’s still hard to explain to them sometimes it’s because Medicare does not pay for chiropractic maintenance care. That’s simple. That’s all you need to put. And then we come over to box. This is box. This is the estimated cost. When we come here, there is a lot of discrepancy out there on what to put. You have two options. Two options are this. You can use your fee schedule, whatever you charged, every one you send off to your highest payer, let’s say pie. Maybe that’s 50, 60, $70 tearing up through those services, or you have the option of using the Medicare allowable fee. And I’ll make sure you’re babysitting that every year, but in order to make sure this is all Bulletproof the whole way through, go ahead and create a policy and say, I am going to use the Medicare allowable fee for the spinal CMT services that are not medically necessary for maintenance.

And then use it, apply it consistently across the board. Don’t hunt and Peck and go this way or that way be consistent. So you’ve got to fill it out. This is part of those five common areas you saw. How many of them we’ve already ticked off right here, this ABN form. Again, make sure something I see all the time. It’s one of my core questions I ask here. When we’re taking in a new client, do you always use the 80 modifier when submitting for spinal CMT services to Medicare? Yes. Do you ever change it? No. I didn’t know. I needed to, we got an ABN. Okay. Something’s not jiving here. The 80 is not something that you use all of the time. Again, you saw on that last slide, it went up, it still made it. And we went to an ABN and a GA modifier.

We came back down, we went to an ATM back up that ABN form is a GA modifier. If it’s signed ahead of time. So the patient has options. Don’t tell them which one to pick. You’re not allowed. However, when it comes to QMB check out that Medicare ABN form, it says you have to tell the QMB patient that they have to pick option one. You can’t have them pick option two. And there’s all kinds of bells and whistles that you have to do in order to fix this ABN form the way they want it for a QMB patient. But this is going to be your I’m a par provider or I’m non-par accepting assignment. This is what your ABN would, would look like. They would choose option one. Should they want you to bill Medicare? You can still charge them. They want you to bill Medicare just so they can see what happens.

Oftentimes you’ll see this when somebody has a true secondary, I’m not going into depth on this, but I do encourage you to keep in mind if you verify that secondary insurance and they do not cover maintenance, that you will alert them. If they do pay you for that maintenance surface option. Two says, I do want the service. Don’t fool with bill and Medicare. I’ll just pay you now, but do understand they can come back within one year and change their mind, make a notation on the ABN stating otherwise. Or they may say option three. If Medicare is not paying, I’m not having this service. And that really should be a cue in your office, that the doctor should be alerted to at least speak with the patient. Uh, but they’re not following medical advice. And maybe the importance of maintenance care hasn’t been reiterated to them, or they don’t understand that importance.

As you see down at the very bottom, we have the new ABN form, what it looks like, and it’s going to expire. Let’s see if they hit their target of six 30, 20, 23. Again, it’s kind of that three year period. That was the date that it obviously got approved. This year was six 30 and we will be using this form. If you’re on still three 11, if you’re on three 2020, make sure this is implemented by the end of this month a quickly, when we’re talking about the Medicare ABN form and you are, non-par not accepting assignment, there are specific rules with the specific rules you have got to cross through one of the last lines in option one. As you see there, one line strike through don’t scribble it. One line strike through. As you see here, if Medicare does pay you a refund, any payments I made to you less pay less copays or deductibles.

It has to be crossed out because you don’t accept assignment. The patient gets reimbursed at home. It just makes that whole option. One make more sense relative to you being par or non-par. They also give some guidance on box H and they say, if you’re going to strike through, because you’re, non-par not accepting assignment. If you’ve gone to strike through that sentence in option one, you’ve got to put this information in box age. Now there’s a reason I didn’t include it today is because the AB inform instruction was better this year. They said, if you are a supplier or provider, then put box H in the past. It’s been, if you are a, say a supplier. Now I went to Medicare a couple of years ago, and I said, wait a minute. You’re saying we’re supplier. Yes, a chiropractor’s a supplier. I could show you the email.

You’ve got to put it there, but it doesn’t make sense. The wording is just not clear. If you’re going to say in your guidance that a supplier and provider have to put it there, then why leave only in that box, a language that you provide the word only supplier. And it really doesn’t make good sense. So we’ve gone back again. Hey, do you realize, thank you for clarifying that it is for the provider and the supplier, but the language is a little strange. Can you clarify that for me? So the jury is still out. You’ll see later, they’re still scratching their head and thinking about it quickly. Let’s switch gears. Let’s go over to that right hand side member, no member mandatory submission. The, uh, the mandatory voluntary. This is over on the voluntary side, the statutorily excluded and it’s all those services listed below.

Medicare said, remember that you don’t have to use the official ABN form. Now think back several screens where I gave you that split. This would be the mandatory ABN, and we had three modifiers. And then we had three down here and it was that middle one. We don’t want to use another one, but the minute you pull out an ABN form for voluntary notice, there’s a whole new set of rules and you have to include another modifier. Save yourself. You saw it back there. It was straight from Medicare. You don’t have to do it. So have your aha moment and just skip it. Here’s what I was talking about right here. That G X modifier, you don’t have to have it. Don’t put yourself through the torture of having to go and put another modifier on there. Use some other type of notice. We can see here, some of their specific languages, the ABN also serves

Optional optional.

Terry noticed that you may use the four Warren beneficiaries. Medicare does not require you to use an AB. And in order to build a beneficiary for an item of service, that isn’t, that is not a Medicare benefit and never covered right. There it is. It’s straight from Medicare. It’s not just from your vet. It’s not just from KMC university, it’s from Medicare. And we can also see when you use here, it goes to that room air leaving. When you issue an ABN form and a voluntary notice that patient doesn’t sign it, they’re like what? And they don’t select option one, two or three. It’s their role. It’s coming straight from them. They don’t do it. That’s why we just feel, why do you even want to go through that? Why don’t you consider? You can it’ll look something similar to this. You don’t put your spinal CMT services on it, but why don’t you just go the route of putting it on your office letterhead and saying, Hey, dr.

Smith, and I would like to welcome you to our, we just want you to know how Medicare acts, they won’t cover these things, but again, if you’re going to do it, don’t list your spinal CT CMT services. Cause that has to be on the mandatory. This brings out that G Y modifier, but you don’t have to include that extra one GX because you use your own forms. So our recommendation, mandatory CMT services, you have to use the official ABN form for, to traditional Medicare for all the other services. Do yourself a favor. Don’t chase your own tail, stick you a signature line on here, have the patient sign it, give them a copy much. Like you are required to give them a copy of that mandatory ABN form. You’ll have it for their records. You have it for theirs. They’ve been notified. You’ve dotted your I’s you’ve crossed your feet and everything’s okay.

Quickly. This is still a huge area where we have asked about six extra questions from Medicare regarding the QNB. And we’re going to be showing you that we are covering those things and asking for those. We talked about it last time, how you can’t bill them for those spinal CMT services when they are with Medicare and an active phase of care. But they went as far as to say, you can’t charge them for the maintenance until the claims adjudicated. We’re asking them like, but wait, you never cover it. We want more information, make it applicable to chiropractic. So we know what we’re talking about. So option one, they, they cross through one line, but they left the last sentence on cross through. We’re asking them, why did you not cross through that? So we’re sitting here and we’re waiting. And it says, says, again, that if you don’t accept Medicare assignment, option one, put box H we’re still asking them about box, age and asking those questions.

But you can see they have, you crossed through more words on this. QMB ABN than you do when you’re, non-par not accepting assignments. So there’s all kinds of new rules that you need to be aware of. And again, we’re asking for clarity for the very last sentence of option one. Why did you not cross it off? Why did you leave it off? When you gave the guidance, you need to explain yourself. They have additional edits that they require it needs to cross over, but in order for it to cross over, you got enrolled with Medicaid, go watch the, the webinar I did back on July 14th, for more information on that. And then it talks even more about what it means if Medicare denies and then Medicaid denies that it, and you can come back and give patient liability back to that patient because you did the ABN form the way they told you to.

And, uh, again, you can see there’s just a lot that came out, but there’s still a lot to be determined when it comes to QMB. However, there is enough information that has been released in those ABN form instructions that you need to be looking at it, making the modifications. You will actually have three different ABNs in your practice. Medicare for the spinal CMT services, you’ll have your par your non-par accepting assignment. That’s one. You’ll have your Medicare not accepting assignment par not accepting that’s two. And then you’ll have your QMB your Q. And B’s going to look a little bit like both of them, it’s really a hybrid, uh, that you’ll have there. And this is just kind of a recap of something that I had in the last, uh, and the last thing that I taught, where you’ve got to have the enrollment with Medicaid to get it all the way through.

We’re asking more questions for you, because we want to know if we’re going to instruct it. They need to be close. Crystal clear, just as a recap, August 31st is your deadline. Get it installed. Now be ahead of the game. Be keeping your ears to the ground is we’re pushing them to give more answers to the chiropractic profession. And who knows. We’re probably answering somebody else’s. This is what I told you about. I’m standing outside that jury box and I’m like, come on, hurry up. You’ve given us a deadline. We want to do it right. We don’t want to do it wrong. And right here, this is the email to me from them. Highlight below down here. Good afternoon. Thank you for your inquiry. We will get back to you after the then internal parties have been able to discuss this. Thank you again. So you can see we’re asking them, we’re still waiting.

We just got that last week and I looked this morning and we’re still have the jury out on that. We ask you, if you would like to join KMC for any of our upcoming events, there is a link here on the screen where you can see all of our upcoming events, click and join them, RSVP for them. We’re here for you. You can see our, our shortlist here. Follow that link, go out to our website and take advantage of all that nice stuff that we offer all the time. Or we may be in your area. I’m going to be in Nebraska, uh, here on the 23rd of August, teaching on Medicare, starting at 8:00 AM in the morning for four hours for CE. So if an of you are going to be there at least wave at me, I think we’ve got some social distancing rules. And as always, if you have a question that we can help you with anything we can do for your practice, reach out to us@infoatkmcuniversity.com and you will see that the phone number is listed there now as for ChiroSecure. Thank you again for having me, but let’s talk about next week. Next week, we have dr. Janice shoes that she will be joining you. She’ll be teaching you next week and you surely don’t want to miss that time again. Thank you. This was your vet Noel CPCO for KMC university on their education director. We look forward to seeing you again soon. Bye. Bye

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