I have a patient that has Medicare, but also has a secondary insurance plan that does cover acupuncture. How do I bill Medicare to get a denial so that I may bill this secondary payer?

This has been an exciting development, of course, Medicare does not cover acupuncture performed by any provider whether an MD or licensed acupuncturist and is an excluded service. However, there are now many secondary plans that a Medicare eligible recipient may receive that does indeed cover acupuncture.

Registered Providers

Unfortunately only registered providers may submit claims to Medicare and acupuncturists are not on the list of providers who may register and as a consequence cannot submit a claim to Medicare. More accurately an acupuncturist can submit a claim but it will not be an accepted claim by Medicare and as a result, the provider will not receive a proper denial or response from Medicare to enable a submission to a secondary payer.

The first step is to verify that this secondary policy does indeed cover acupuncture, assuming it does inquire if this secondary will make payments directly to the acupuncture provider without a denial, considering that Medicare excludes acupuncture. I have found this may work for some payers and if they do allow such it solves a lot of added work. If they will accept a direct claim I do recommend all CPT codes on the billing to include modifier GY. This is the modifier used to  indicate that the services are excluded by Medicare.

This secondary plan should not only pay for the acupuncture, but also other services associated with the acupuncture care plan including evaluation and management services and physical medicine should they too have been applied.

Getting the Denial

If they will not pay for acupuncture without a denial from the primary (Medicare) you will need to have a denial from Medicare. But Medicare will not accept a claim nor send a denial to an acupuncturist. Consequently, the patient or you (on the patient's behalf) need to send a claim to Medicare but this is a claim is technically not direct from the acupuncturist but from the patient.

To do this properly you must use the Medicare form 1490S - Patient's Request for Payment. Specific instructions and the address to send the form are included, as the mailing address varies by state.

The provider will have the patient or they may complete the form and attach a 1500 claim for the acupuncture related services. In addition, include a letter or not stating "this claim is being sent solely for a denial of acupuncture so that a secondary plan with acupuncture benefits can be billed." This is to assure Medicare is aware that there is only a need for denial and that there is a clear  understanding that we understand there are no acupuncture benefits from Medicare.

I emphasize do not send a direct claim from the acupuncture provider but from the patient with this form,  so it is clear that a claim for a non-Medicare provider and service is being submitted but only for the purpose of denial. The patient (not the acupuncturist) will receive a denial or response from Medicare in about 30-90 days.

Explaining the process With the Patient

It is imperative to make your patient aware they will receive the denial and that once received they must forward directly to you so that you can use it to submit to their secondary insurance. Of course, you could also have the patient pay at the time of service and once they receive the denial from Medicare they may forward to their secondary payer and have reimbursement sent directly to them. They would need a second bill to send to this carrier attaching the Medicare denial.

If you are directly billing you would bill as normal (including the GY modifier) and attach the EOB or denial from Medicare. The secondary payer would then make payment based on the benefits of the plan. The denial should likely be a statutory denial and that same denial can be used with all claims for that patient.

Also, there are many plans that may replace Medicare. These are often referred to as Medicare Part C plans and are generally PPOs or HMOs and they too may offer acupuncture benefits. These plans do not require a denial from Medicare as they are primary and replace Medicare. These plans may be billed directly with no denials but may limit reimbursement to "in-network providers." Some of the plans, however, will pay providers whether the provider is in or out of network. Be sure to inquire specifically when doing your insurance verification.