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Monday, March 13

GROW: The Bs, Cs, and TBDs of Medicare Billing

Kate Krajci, LCSW

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"What are your thoughts and experiences of billing Medicare in private practice?" I asked.

"Don't do it," replied the presenter at a session about private practice basics.

A sense of dread washed over me. My plan was to open an older adult and family caregiver–focused private practice. I anticipated the majority of my clients would have Medicare. While I knew some geriatric specialists do not accept Medicare, that did not feel like the right choice for me despite the financial benefits to me as the practitioner-business owner. So I did some deep breathing as my anxiety about starting a practice was heightened by the daunting entity known as Medicare.

The basics

The pre-existing knowledge I had about how Medicare works was immensely helpful as I became my own biller. I strongly suggest learning a bit about Medicare's structure, benefits, costs, and terminology to help you prepare for being a provider and understanding how you are getting paid. Basics can be learned at www.medicare.gov or www.medicareinteractive.org. A few key points include:

  • In an outpatient or private practice setting, LCSWs will be Part B providers. Once an annual deductible is met, Part B covers psychotherapy at 80% of the Medicare contracted amount. 20% of the Medicare contracted amount will be the client's co-payment.
  • Some clients will have a supplemental insurance that is standardized across private insurance providers. These formal, standardized private supplement plans are interchangeably called Medicare supplement insurance, MedSupps, or Medigap plans. Medigap plans work with Medicare Part A and B. They cover the client's 20% co-payment, and a few also cover the Part B annual deductible.
  • Some clients will have selected (or received as a retiree benefit) a Medicare Advantage Plan, also known as Medicare Part C. Advantage plans offer the same Medicare Part A and B benefits, but the benefits are managed and administered by a private insurance company instead of Medicare. Advantage plans can be structured as a PPO, HMO, or several other payment and provider network structures. You are still held to the Medicare contracted amount, and the plans generally pay the full amount.
  • In Illinois, there is also the Medicare Medicaid Alignment Initiative (MMAI). This type of managed care applies only to Medicare beneficiaries who also have Medicaid.
  • Your claims are not processed directly by Centers for Medicare and Medicaid Services. They are processed by a Medicare Administrative Contractor, which for Illinois Part B providers is National Government Services (NGS). Advantage plan claims are processed by the insurance company that offers the plan.

Ready, set, bill!

Even with Medicare knowledge, I often felt confused and overwhelmed during the enrollment process and when initially submitting charges. I was helped immensely by a colleague who had recently enrolled in Medicare for her private practice. There are a few intricacies to the application process to which my colleague thankfully alerted me. In addition, calls to Medicare provider enrollment were generally helpful, especially when I explained I was a clinician completing the paperwork myself as opposed to an employee of an organization who routinely submits applications. I found asking simple questions, giving examples, and pushing for non-jargon responses to be effective in obtaining the information I needed to be confident that my application was completed correctly. I also chose to submit on paper by mail instead of using the online PECOS system. It ultimately took me less time to compile and complete all of the paper applications than the time I lost trying to understand PECOS.

Once you are an approved provider, as with other insurances, you are limited to the Medicare contracted rate for your profession and geographic area. The contracted rates change annually on January 1. You can find the fee schedule on the NGS website by selecting the "CP/CSW" fee schedule and your geographic region (find the number that corresponds to your location at the bottom of the fee schedule search page). If you select "full fee schedule,” you will get a list of all CPT codes that apply to LCSWs along with the corresponding contracted rate. Frustratingly there is a minor reduction in the rate due to sequestration that is not reflected on the fee schedule. Though minor, when the majority of your clients are Medicare beneficiaries, this reduction adds up. Regardless, it is my understanding that Medicare contracted rates are competitive with some of the higher reimbursing private insurers which, in my opinion, break the myth that Medicare is a poor payer.

In addition to the full fee schedule, you can learn CPT codes for which LCSWs can bill by using the "LCD/policy search" on the NGS homepage. The Local Coverage Determination (LCD) gives specific information on allowable CPT codes, diagnosis codes, required documentation, and limitations. Searching "clinical social worker" will result in relevant LCDs.

So you're enrolled as a Medicare provider, you know what you can bill, and how much you can expect to be paid. But how do you submit charges when your Medicare clients may have Medigap supplements or even an Advantage plan? This was definitely a source of worry for me as I prepared to open my practice. Any claims submitted to Medicare Part B will automatically be sent to any secondary insurance Medicare has on file for the client. You do not have to enroll in the various private insurance policies that offer Medigap plans. My experience with this has been seamless, though some Medigap plans take longer than others to pay. Regarding Advantage plans, I have only seen clients who have PPO structured plans. I was not required to enroll as a provider with these insurers; however, some have been difficult to submit claims to or take a very long time to pay.

I definitely had moments when I considered hiring a billing service but ultimately by asking colleagues who bill Medicare, calling Advantage plan provider lines, and learning from a few minor errors, I now have a relatively efficient system in place. Your choices for submitting your own claims certainly include the typical clearinghouses like Availity and Office Ally, but if you see a high number of Medicare clients you likely will have to pay a monthly fee. NGS offers two free billing services: PRO-ACE software for download and the NGSConnex online service. PRO-ACE does not support the Macintosh operating system, so I opted for the NGSConnex service. Again there were some nuances to getting access, but the NGS provider line was extremely efficient and helpful in getting me started. They also were responsive when I asked for assistance in understanding how to use the system and submit a claim since I had never done so before. The downside to NGSConnex is that at least at time of writing, it does not allow you to save client information—you must manually enter information each time you submit a claim. You also cannot submit Medicare Advantage claims via NGSConnex. Advantage plan claims need to be submitted directly to the insurance company.

To Be Determined (TBD): Billing challenges

There are days my head still spins regarding billing, but the headaches are well worth working with the population of clients I most enjoy. Yes, I could have a more profitable practice if I was not a Medicare provider, but I also would not be able to serve the clients who cannot afford to not use their hard-earned benefits. While I have grown in my confidence in billing Medicare, outstanding issues still remain.

First is how to bill Medicare clients who also have Medicaid, especially relating to the complexities of the Medicare Medicaid Alignment Initiative (MMAI).

Second, there are subtle nuances to Medicare that do not necessarily apply to some privately insured clients. For example, you cannot bill a Medicare client for missing an appointment or cancelling at a late hour. Telehealth for psychotherapy is only allowed in rural areas at this time. These details are not easily learned. Thankfully, the NASW-Illinois Chapter has worked in collaboration with CJE SeniorLife, Northwestern Medical Group, and Rush University Medical Center Health and Aging to obtain clarification from NGS on many of these issues. I have had the pleasure of working with this group to represent individuals in private practice. An issue brief from NGS tailored to social workers will soon be available.

Finally, LCSWs have the skillset to provide Medicare-reimbursable services in addition to psychotherapy, but they are not currently approved as providers or independent providers of these services. The collaborative group mentioned above continues to advocate for LCSWs to be approved as independent providers of several care coordination CPT codes as well as the health and behavior assessment and intervention codes. While advocacy around these Medicare billing issues may take an extended period of time, Medicare providers can hope billing processes for any additional codes will follow what we've already learned in our practices.


Kate Krajci, LCSW, is founder of Life Changes Counseling and Care Planning, a private practice in Chicago's Loop that also offers in-home psychotherapy and consultation. She specializes in aging, caregiving, dementia, chronic illness, disability, and grief. Prior to opening her practice, Kate managed a team of social workers integrated into outpatient medical practices and conducted psychotherapy with older adults and caregivers in hospital- and community-based settings.

Posted on 03/13/17 at 08:00 AM

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