How Payers Not Paying Affects Providers

April 8, 2017

Do you have fail-safe measures in place that alert you when a payer is withholding your payments? If not, it's time to make a plan.

As a provider or practice administrator, are you aware of all accidental or purposeful withholdings of your payments from payers? Medicare payer, Noridian Healthcare Solutions recently dropped a bomb on Part B rehabilitation therapy providers, stating "Claims and adjustments are denying for therapy limitations when the KX modifier is present." 

Well, this is perfect timing since a majority of patients are nearing their $1980 therapy cap for 2017.  What does this mean?  Several years ago, changes were made with Medicare and patients seeking outpatient rehabilitation.  An amount cap was placed on all Part B services to limit the number of therapy visits patients can have.  Each year, the amount has gone up approximately twenty dollars.  This year (2017) that amount is at $1980.00.  That's approximately 20 visits in hours of therapy time.  There are many instances where patients require more than approximately 20 visits, so a modifier is then placed in with the billed charges alerting Medicare that the patient is still working on their plan of care and needs more visits to complete the course of therapy.  The requirement to use the KX Modifier is medical necessity and proof that the patient is improving.  By utilizing this modifier, the patient can then be seen for a total allowed amount of $3700, which is approximately 35 visits. 

If this seems like a LOT of visits, keep in mind the patient population requiring therapy.  Many patients in this age bracket are fall risks, often needing surgery following an accident or fall.  This is also an annual benefit, so once all of these visits have been used up for the year, that's basically it.  Yes, there are exceptions and the representatives at Medicare will tell the patient they can be seen as much as they need to be, but then you as the provider are setting yourself up for an audit.  With these types of patients, this benefit is really a necessity in their lives, as patients tend to hurt themselves more than one episode of care per year.

All of this said, the bombshell that Noridian dropped is basically saying, "Sorry Mr. Provider, you're not going to get paid for any patient that is using the KX Modifier right now."   So, now providers are scrambling (again) because a) they are not being paid, b) they have to track those claims that already went out, c) they have to monitor that the secondary insurance did not pay the claim because Medicare denied it, and if they did pay, the provider is required to refund that secondary payer, and d) they have to request interest on those late payments and track that as well.  All because Noridian's computer system suddenly changed and started denying these types of claims.  Something sounds a little fishy to me.  In the industry we've heard it should take approximately two weeks to get fixed, but Noridian's alert system is not showing a completion time frame.  

I don't know why several payers are pulling out all of the stops to not pay providers, but these types of moves really effect the provider's bottom line.  Some business owners have had to tap into their savings or take out lines of credit to make ends meet and provide payroll for employees trying to find other avenues of revenue (clean up old claims, reprocess incorrectly paid claims, etc.).  The provider always seems to get the hit when payers don't want to pay.  Be aware of these types of scenarios and know your payers timely payment deadlines and hold them to those.