Chiropractic is one of the specialties that are required to have a contract in order to treat Medicare patients. If a chiropractor does not have a Medicare contract, they are required to refer Medicare patients to another chiropractor who does have a Medicare Contract. This is true even for chiropractic services that are non-covered by Medicare, such as maintenance care.
This rule can be found in Chapter 15 of the Medicare Benefit Policy Manual in Section 40.4. It states; "the opt out law does not define "physician" to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract."
There has been a confusing notion in the chiropractic profession that chiropractors can have the patient sign an Advance Beneficiary Notice and bill the patient without being a Medicare provider. This isn't true.
The No Opt Out Rule for chiropractors in the Medicare program means a chiropractor can treat a Medicare patient either as a participating provider or a non-participating provider, but either way, the chiropractor has one of the two contracts with Medicare; a participating contract or a non-participating contract.
A Medicare participating contract means the chiropractor has physically signed a contract with Medicare, agrees to abide by all the rules of the program, bills Medicare and accepts assignment from Medicare. A Medicare non-participating contract means the chiropractor has physically signed a contract with Medicare, agrees to abide by all the rules of the program, but has a choice whether or not to accept assignment.
There is one more catch, a non-participating Medicare provider is still limited by how much the patient may be charged. There is a limiting fee schedule whereby the chiropractor may only bill the Medicare patient up to 115% of the allowed Medicare fee even if the chiropractor does not accept assignment and the patient receives payment directly from Medicare.
There is a good handout published by CMS called "Misinformation on Chiropractic Services" that covers this rule and many others. For a copy of this handout, search for it at www.cms.gov and it will be readily available. If you are unable to find it, please email firstname.lastname@example.org with the subject line stating; "Misinformation on Chiropractic Services" and you will receive a return copy.
Billing Buddies ® Bullet Points is brought to you by Billing Buddies. Visit us on the web at www.billingbuddies.com. I'm your host, Bonnie J. Flom. I have 34 years of medical billing experience and am a Certified Medical Reimbursement Specialist through the American Medical Billing Association. If you have any questions or comments, please email email@example.com or call or text 612.432.2366. Our goal at Billing Buddies is to help optimize and expedite our providers' reimbursement so they are better able to serve their clients. If you should need medical billing or training services, please contact us. Have a great day and happy billing.