EOB explaination/ non par chiropractic care

rgski

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Can someone please help me? I work for a clinic that does not accept insurance of any kind, we have a pt who submitted for reimbursement on chiropractic care. He has brought in his EOB that has us a bit confused.Could someone please explain the following paragraph:

THIS PROVIDER DOES NOT PARTICIPATE WITH MEDICARE. UNDER FEHB LAW (5 U.S.C.8904 (B)), WE ARE REQUIRED TO BASE OUR PAYMENT ON THE MEDICARE FEE SCHEDULE AMOUNT OR THE PROVIDER'S CHARGE WHICHEVER IS LESS FOR SERVICES PROVIDED TO FEDERAL RETIREES AND ANNUITANTS WHO ARE AGE 65 OR OLDER AND ARE NOT ENROLLED IN MEDICARE PART B. SINCE THIS PROVIDER DOES NOT PARTICIPATE WITH MEDICARE, HE/SHE CAN BILL YOU UP TO THE MEDICARE LIMITING CHARGE. YOU ARE NOT RESPONSIBLE FOR ANY AMOUNTS OVER THE MEDICARE LIMITING CHARGE. THE MEDICARE LIMITING CHARGE MAY BE CALCULATED AS 115% OF THE ALLOWANCE. PLEASE SEE YOUR BLUE CROSS BLUE SHIELD SERVICE PLAN BROCHURE FOR MORE INFORMATION.

YOUR RESPONSIBILITY TO THE PROVIDER IS $31.20 WE PAID $17.64
THE PROVIDER CAN COLLECT $31.20 FROM YOU FOR THESE SERVICES.

We charge $55.00 for manipulations at the time of visit, do we need to change our charge rates?? We do not do any insurance billing.

Any help would appreciated greatly!!
R
 
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Can someone please help me? I work for a clinic that does not accept insurance of any kind, we have a pt who submitted for reimbursement on chiropractic care. He has brought in his EOB that has us a bit confused.Could someone please explain the following paragraph:

THIS PROVIDER DOES NOT PARTICIPATE WITH MEDICARE. UNDER FEHB LAW (5 U.S.C.8904 (B)), WE ARE REQUIRED TO BASE OUR PAYMENT ON THE MEDICARE FEE SCHEDULE AMOUNT OR THE PROVIDER'S CHARGE WHICHEVER IS LESS FOR SERVICES PROVIDED TO FEDERAL RETIREES AND ANNUITANTS WHO ARE AGE 65 OR OLDER AND ARE NOT ENROLLED IN MEDICARE PART B. SINCE THIS PROVIDER DOES NOT PARTICIPATE WITH MEDICARE, HE/SHE CAN BILL YOU UP TO THE MEDICARE LIMITING CHARGE. YOU ARE NOT RESPONSIBLE FOR ANY AMOUNTS OVER THE MEDICARE LIMITING CHARGE. THE MEDICARE LIMITING CHARGE MAY BE CALCULATED AS 115% OF THE ALLOWANCE. PLEASE SEE YOUR BLUE CROSS BLUE SHIELD SERVICE PLAN BROCHURE FOR MORE INFORMATION.

YOUR RESPONSIBILITY TO THE PROVIDER IS $31.20 WE PAID $17.64
THE PROVIDER CAN COLLECT $31.20 FROM YOU FOR THESE SERVICES.

We charge $55.00 for manipulations at the time of visit, do we need to change our charge rates?? We do not do any insurance billing.

Any help would appreciated greatly!!
R

I know this seems super confusing, but I'll try to explain it in basic terms. (You'd be looking at #3)

There are three ways a provider can have a relationship with Medicare, and that appears this payer is following the same guidelines.
1. The first is a participating (PAR) provider who accepts assignment: this means the provider (obviously) participates with MC and agrees to accept whatever payment MC makes as payment in full. They get paid at 100% of the MC fee schedule. The payment goes directly to the provider.

2. The second is a non-participating (non-PAR) provider who chooses to accept assignment: the provider doesn't participate, but agrees to accept whatever payment MC makes as payment in full (assigned claim). They get paid at 95% of the FS. The payment goes directly to the provider.

3. The third is a non-PAR provider who doesn't accept assignment: the provider doesn't participate and doesn't agree to accept the MC payment as payment in full (unassigned). They ARE restricted to the amount they can bill a MC patient, however. It's referred to as a "limiting charge" which is 115% of the non-PAR FS allowed amt (95%). The payment from MC goes to the PATIENT, not the provider.


I assume you enter CPT codes for the service in your system (?) and then bill the patient for the $55.00? What CPT code are you using? Is this from the primary payer?
 

avon4117

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First of all medicare does not pay 100% per cent of anything. They pay 80% of the medicare allowable.

Second of all if you review the medicare fee schedule there are non par amounts. So you can based that to determine patient responsibility per CPT.
 
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First of all medicare does not pay 100% per cent of anything. They pay 80% of the medicare allowable.

Second of all if you review the medicare fee schedule there are non par amounts. So you can based that to determine patient responsibility per CPT.

The question is about the limiting charge (which is 115%), not the non-PAR allowed amounts (which are 95% of the fee schedule). If the provider is PAR, the provider accepts MC's allowed amount as payment in full. That doesn't mean Medicare is paying at 100%. The allowed amount is different from an actual payment. And the non-PAR allowed amount is different than the limiting charge.
 

avon4117

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I am a little dusty on how medicare pays for non par providers because I have never worked for one. (non medicare provider) But after doing some research..you are right, medicare does pay non par provider 95% of the fee schedule. But the provider can only charge 15% over the amount that non providers are paid..right?
 
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I am a little dusty on how medicare pays for non par providers because I have never worked for one. (non medicare provider) But after doing some research..you are right, medicare does pay non par provider 95% of the fee schedule. But the provider can only charge 15% over the amount that non providers are paid..right?

It's easier to understand if you look at an example.

In this case, let's say Medicare's Fee Schedule Amt is $200

MC limiting chg.jpg

The key about non-PAR providers is whether they accept assignment or not. For any payment arrangement however, anything above and beyond the payment rate would be a write-off.
 
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rgski

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EOB explanation /non part chiropractic care

I appreciate all the responses and it has helped somewhat. My confusion still is... we do not accept or bill any insurance. We charge $55 at time of visit from all pts. This pt submitted a MEMBERS CLAIM FORM to his BCBS Federal Employee plan for partial reimbursement of the $55 he paid out of pocket. He is now under the impression that we (the provider) are not allowed legally to charge more than $31.20 for his manipulations. We provided code 98940 3-4 manipulations, because he stated he was going to submit member claim for for reimbursement.
 
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I see what's going on now. I'll try to explain it the best I can because it's incredibly confusing. First, BCBS FEP works just like Medicare generally speaking and can use the limiting charge rule.

Under certain circumstances, Medicare would pay for 98940. Because the service is a benefit for Medicare, it's subject to the "limiting charge" rule for a non-PAR unassigned claim. The only way a provider can charge a patient the full amount is if they Opt-out. Unfortunately, chiropractors aren't given the option to Opt-out, so even though this is a non-PAR unassigned claim, because your provider does not have the ability to opt-out, and because he/she treated the patient, he/she is subject to the "limiting charge". Had BCBS FEP denied the claim as non-covered, then it would be a different story.

The MC FS amount for 98940 is $28.64. Non-PAR gets 95%, or about $27.21. Unassigned limiting charge gets 115% of $27.21 or $31.29 (which is basically how they got to $31.20). Due to the opt-out situation, you're pretty much stuck on this one.

ABNs can be used if the service is expected to be denied, but if you get an ABN, you have to submit a claim. If you go to the link below, it says "A chiropractor who chooses not to enroll has freed him- or herself of all Medicare rules and requirements except one: he or she can’t treat any person for any condition that is a covered service under Medicare."

http://www.lexology.com/library/detail.aspx?g=98b4d0fd-5bdc-4864-9b57-7226e1d7234a


This is for the FEP info:
https://www.opm.gov/healthcare-insu...ormation/plan-codes/2016/brochures/71-005.pdf - see pg 128 and 143.
 

rgski

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EOB explanation /non part chiropractic care

I thank you so much for your time and guidance! So reading the articles and your response do we need to reimburse the patient $23.80? OR because BCBS FE reimbursed pt $17.64 do we need to reimburse $6.16 to the patient?
 
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I thank you so much for your time and guidance! So reading the articles and your response do we need to reimburse the patient $23.80? OR because BCBS FE reimbursed pt $17.64 do we need to reimburse $6.16 to the patient?

BCBS paid the patient $17.64, which would have gone to you if you had accepted assignment and billed. The $17.64 is due to YOU and since the pt received it, he is responsible for giving you that money, because it's yours. The additional $13.56 could be partially a copay or coinsurance + the limiting charge allowance, or it could just be the limiting charge allowance flat out. Either way, the patient also owes that amount to you. So in total, you should be getting the whole $31.20.

Since the pt paid the $55 at the time of the visit (I assume), the difference of $23.80 would be due back to the patient. If he did not make any payment, then he would owe you the $31.20 and the $23.80 would have to be written off.
 

rgski

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EOB explanation /non part chiropractic care

The patient did pay $55 at the time of visit and received $17.64 check with the EOB. He is believing we owe him because it stated in the EOB we could not charge more than $31.20. So he is correct? And we owe him $23.80?
 
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The patient did pay $55 at the time of visit and received $17.64 check with the EOB. He is believing we owe him because it stated in the EOB we could not charge more than $31.20. So he is correct? And we owe him $23.80?

You can only bill him $31.20. The $23.80 would have to be refunded, yes. :(

Scenario 1:
The patient paid nothing at the time of the visit.
YOU billed BCBS for the $55.00. BCBS would have responded with an EOB that said something like this:
Billed Amt $55.00
Allowed Amt $31.20
Adjustment Amt aka Write Off $23.80 ($55 - $31.20, not billable to the patient) - per fee schedule + limiting charge
Amt Paid to Provider $17.64 (as you would have gotten that check)
Pt Responsibility $13.56 <-- this is what you would bill him.

Scenario 2:
The patient paid nothing at the time of the visit
HE billed BCBS for the $55.00 BCBS would have responded to HIM with an EOB that said:
Billed Amt $55.00
Allowed Amt $31.20
Adjustment Amt aka Write Off $23.80 ($55 - $31.20, not billable to the patient) - per fee schedule + limiting charge
Amt Paid to PATIENT $17.64 (as HE would have gotten that check)
Pt Responsibility $13.56
Total Amount Due to Provider $31.20 (the BCBS check + the pt responsibility + the limiting charge of $) <-- this is what you would bill him.

Scenario 3 (YOUR CURRENT SITUATION):
He paid $55.00 at the time of the visit
HE billed BCBS for the $55.00 BCBS would have responded to HIM with an EOB that said:
Billed Amt $55.00
Allowed Amt $31.20
Adjustment Amt aka Write Off $23.80 ($55 - $31.20, not billable to the patient) - per fee schedule + limiting charge
Amt Paid to PATIENT $17.64 (as HE would have gotten that check)
Pt Responsibility $13.56
Total Amount Due to Provider $31.20 (the BCBS check + the pt responsibility + the limiting charge) <-- this is what you would have billed him had he not paid.
This now means that he overpaid you $23.80, so he is due that money back.

From an accounting perspective:
Billed charge $55.00
Adjustment -$23.80 (amt over limiting charge)
Acct Bal $31.20 (patient responsibility + BCBS payment owed to you)
Patient Paid +$55.00
Acct Bal -$23.80 <---- this becomes negative because HE overpaid you. He paid you $55 when he should have only paid $31.20.
Refund to pt $23.80
Acct Bal $0
 
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