Medical Mutual Updates

MMO Policy Update (5/9/19) – We are continuing to communicate with Medical Mutual on their new chiropractic policy intended to create clarity going forward. We have been told that this policy is still planning to be introduced soon, but is currently still in committee at MMO. We will inform all members as soon as we have recieved these policy updates.

(2/7/19) Update for Medical Mutual of Ohio Issue
The OSCA continues to work on issues that affect our members regarding Medical Mutual of Ohio (MMO).The two most recent issues involve the use of CPT code 97124 and the use of the 59 modifier, most frequently used with 97140.

As phone calls and written communications by the OSCA to Medical Mutual have not resulted in a productive dialogue, we have requested an in-person meeting.We expected this meeting to take place in the first week of February.This date has been pushed back, and at the request of MMO, will be scheduled as a teleconference.

The OSCA brought the findings from the most recent Opioid Reduction Report to MMO’s attention. This report lists that insurers should reallocate funds to cover non-opioid services such as chiropractic, acupuncture, massage therapy, physical therapy, meditation and cognitive behavioral therapy as their number one recommendation.Medical Mutual participated in the task force that created this recommendation.We would like to have a better understanding of how their current policies, and enforcement of those policies, helps to increase access to the recommended conservative treatments for those insured by MMO.

This report goes further in the first recommendation to suggest that insurers should review their policies on bundling services as this practice can be dis-incentivizing to providers, making it more difficult for patients to receive these conservative treatments.We would like MMO to explain their bundling policy specific to 97140 and whether their current policy makes it more difficult for patients to receive this and other conservative services.

We would also like to bring to their attention that the current administrative/provider services structure has created several challenges for our providers that have led to confusion or misunderstanding of benefits, both for our providers and the patients they serve.This includes, but is not limited to:

  • Incorrect verification of benefits when the provider calls provider services
  • Misquoting of benefits when the insured/patient calls customer service
  • Inability to receive SPD in a timely manner, or at all, when it is requested by the provider and/or the insured/patient

Although through previous communications we have attempted to convey this and other concerns, the upcoming teleconference will be an opportunity to discuss this with MMO leadership, including their Medical Director.

We have two goals:

  1. To ensure that our providers have a reliable, consistent, and easy to access method to understand MMO policy, and the limitations to the services our members provide.
  2. Have an opportunity to present a differing perspective on MMO policies we may disagree with, in an attempt to improve access to conservative care options that are evidence based and are included in best practice recommendations.

To give some historical perspective on the issues related to the codes in question, the NCCI (National Correct Coding Initiative) committee is a committee of the Centers for Medicare and Medicaid.“The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.”Although these edits are specific to Part B claims, the committee releases a report of their edits each year for transparency.Other 3rd party payers have chosen to adopt these billing edits.The edits effect all health providers and professions, not just Doctors of Chiropractic.As far back as 2003, we can find documentation of the edit that effects 97140, 97124 and 97112 when performed at the same time as CMT.We have reached out to this committee to request that they review and remove this edit.We have spoken with the Medical Director for this committee and provided 3 written appeals for removal.We are currently awaiting a requested conference call with the committee and the corresponding Medicare representative.Although we may not be able to succeed in removing this edit, we feel it is important to exhaust all options available.As we see it, this is an edit that was created by Medicare, yet has no effect on Medicare beneficiaries, as Medicare explicitly limits coverage to CMT only.However, this edit is having unintended consequences by giving 3rd party payers the basis to deny the services in question.

Based on feedback we are hearing from membership, it is important to address some questions and misconceptions.

Membership concern: “If we receive no update, we assume no work is being done.”

OSCA response: We hear you.And will do a better job of letting you know.Even if the update is “no change, but we’re still working on it.”

Membership concern: “By quoting and/or making membership aware of MMO policy regarding massage, the OSCA agrees or sides with MMO.”

OSCA response: This assumption is incorrect.Regardless of whether you understand or agree with a policy as a network provider, you are still responsible for providing services consistent with the policy and the contract you signed.As soon as the OSCA becomes aware that there may be confusion leading to member audits, it is our responsibility to provide clarification.Furthermore, just because a service is within your SCOPE to perform or DELEGATE does not automatically mean that it is a service covered by or billable to a payer.Misrepresenting the rendering provider on the HCFA form, or changing the CPT code, to circumvent a benefit limitation, does not make it an acceptable billing practice, even if done so unknowingly.

Having said all of that, we can work to CHANGE policies going forward.HOWEVER, if and until a policy change is made it is your responsibility to make sure that your performed and billed services are done so compliantly.

The most challenging thing when dealing with these types of issues is that we can make the right argument at the right time, yet we don’t control the time frame or the outcome.What the OSCA can assure you of is that we are still pushing, fighting, and working on these and other issues every day, for every DC.When one door closes, we don’t take no for an answer.We open the next door, employ the next strategy.

We are working for you so that you can do what you love each day!It is not an easy fight, but it is a worthwhile one and one we will not give up!

 

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