Kathy’s Monthly Chronicles – The American Chiropractor

Your Business Associates and Your HIPAA Responsibilities

:dropcap_open:R:dropcap_close:ecent changes (again) have beefed up what healthcare providers must do to protect patients’ information in the office, and have many providers scratching their heads and worrying about one more compliance issue. While HIPAA Privacy addresses the protection and disclosures concerning all protected health information (PHI) created or received by a practice (including oral, written, and electronic PHI), HIPAA Security addresses, more strictly, the protection of electronic protected health information (ePHI). ePHI is described as protected health information that is created, stored, accessed, maintained, or transmitted electronically. One of the most important requirements of your HIPAA Security Program is the Business Associate Agreement (BAA) rules and guidelines. You may often use the services of a variety of other people or businesses to carry out your chiropractic business functions. The HIPAA Security Rule allows you to disclose and transmit patients’ ePHI to these “business associates” if you obtain satisfactory assurances that the business associate will use the information only for the purposes for which this associate was engaged by your office, will safeguard the information from misuse, and will help you comply with some of your duties under the Security Rule.

Ask yourself the following questions:

Do you have contracts in place with outside entities entrusted with ePHI generated by your office?
If so, do the contracts provide assurances that the ePHI will be properly safeguarded and used only for the intended purpose?
For the software vendor you use for practice management, do you have assurances that the products are HIPAA compliant?
Is your massage therapist an independent contractor? Do you have a BAA with him/her with proper assurances in place?
When you contact consultants for assistance, do you ensure you have a BAA in place before sending ePHI?

Remember, you are ultimately responsible for your patients’ ePHI and obtaining a BAA with those you do business with is part of your compliance plan, and therefore your responsibility. Business associates are also held to the standards of HIPAA and are subject to civil and criminal penalties as well.

There may be situations when a business associate pushes back when asked to sign a BAA with your office. The reasons are numerous, including not wanting to hire an attorney to review the agreement, not fully understanding why a contract must be signed, or simply the belief that it will create too big of a legal responsibility for them. You have to stay in charge! When such resistance does occur, use the following scripts to help handle the situation appropriately:

SCENARIO 1:

Dr. Parker: “Hi Mary, I know we’ve been working together for years, and you’ve always done such a great job handling my billing. I am updating my compliance policies and procedures in my office to the HIPAA rules and regulations. I’ve learned a lot about my responsibilities for protecting my patients’ health information, and yours as well as a business associate”

Mary: “What is this agreement all about? I’m not sure I want to sign any agreement.”

Dr. Parker: “Oh, the agreement simply says that you won’t use my patients’ information in any way other than for the agreement we have for you to do my billing. It says you’ll protect that information and make sure it doesn’t get mishandled in any way. You’ll see in the contract. But no worries, Mary, it’s all the stuff I’m sure you’ve been doing the whole time. I am simply required to have this contract on file here in the office since you are an independent contractor.”

Mary: “Oh, no problem. E-mail it to me and I’ll get it back to you later today.”

SCENARIO 2:
Dr. Parker: “Hi Mary, I know we’ve been working together for years, and you’ve always done such a great job handling my billing. I am updating my compliance policies and procedures in my office to the HIPAA rules and regulations. I’ve learned a lot about my responsibilities for protecting my patients’ health information, and yours as well as a business associate”

Mary: “What is this agreement all about? I’m not sure I want to sign any agreement.”

Mary: “Well, I’m just not big on contracts. I’d have to hire an attorney to review it, and that’s expensive. I’ll read it but I have to tell you, I don’t think I’ll be signing it.”

Dr. Parker: “It’s really straightforward. I’ll send it for you to read. I want to continue working with you because you do an awesome job for us, but I’m responsible for this requirement. Whoever is doing my billing has to agree to protect my patients’ ePHI, and that person has to agree in writing. I’m bound by these rules and regulations or could face a hefty fine. I’m sure you understand. I’ll send it over. You take a look and we’ll decide if we can move forward working together once you’ve made a decision about signing.”

Because you are responsible for having these documents on file, you can’t allow a business associate to function on your behalf, using your ePHI, without consent to the assurances you have in your BAA. Once you have received this BAA from all of those who work with your practice, make sure you log and date the receipt of a signed BAA and keep this log in your HIPAA Security Compliance Manual. Your documentation of this transaction is equally as important as the transaction itself per HIPAA Security documentation standards.

There are circumstances when a BAA is not required, such as:

Sending ePHI to another healthcare provider when it concerns the treatment of a patient.
A person requesting a copy of his or her own ePHI.
For those who work as W2 employees in your practice.
When an independent contractor has no access or authorization to PHI (keep in mind, HIPAA Privacy addresses PHI in all forms, so these independent contractors can have access to no PHI, not just ePHI, otherwise HIPAA Privacy requires a BAA).

Remember, you patients’ PHI is your responsibility. Don’t miss this crucial piece of your compliance program. Start now with the business associates you currently utilize for services and each time you retain a new associate for services, be sure that the BAA is signed before he or she ever receives or has access to your patients’ ePHI. Having your compliance in place and active in your practice allows for fearless care of patients and ease in daily business functions!

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy is known as one of our profession’s foremost experts on Medicare and can be reached at (855) TEAMKMC or [email protected]

Use a Pre-Acceptance Interview for Better New-Patient Communication and Conversion

:dropcap_open:S:dropcap_close:ome doctors struggle to keep a steady flow of new patients. One of the reasons we hear the most often for new-patient numbers that are lower than average is difficulty explaining initial finances when a patient calls and asks the question, “How much does it cost to see the doctor?” As many as 60 percent of the inbound calls to offices asking about fees can be lost if mishandled by the front desk. One of the most dangerous examples of mishandling occurs when new patients are offered free or ridiculously discounted initial exams or first visits. Giving away initial care, or any care, is considered an inducement. To help you avoid the risky pitfall of inducement, it is necessary to follow specific procedures and scripts. Having a set phone script for new-patient “shoppers” along with a “pre-acceptance interview” process is excellent for practices that wish to offer patients the chance to find out if they are a good candidate for chiropractic care without any financial risk.

:quoteright_open:Having a set fee for the initial visit that is legally discounted makes your new-patient scheduling so much easier than ever before.:quoteright_close:

Just about anyone who has answered a phone in a chiropractic office has fielded the question about how much the doctor charges. Each of us has also proceeded to do the “Texas Two-Step” dance around that question. The truth is that we really do not know what the fee would be for a particular patient’s required care, but we do have a general idea of how much an initial visit usually costs. Depending on the answer we give, it could be the difference between a scheduled visit and a dial tone in our ear.

Patty the Possible Patient: “Um, hello…can you tell me what it costs to see the doctor?”

Sally Sunshine at the Front Desk: “Well, that depends on what your insurance company allows.” (Scripts are meant to assist with screening those who are Uninsured or Partially Insured)

Patty the Possible Patient: “Oh, I don’t have insurance.”

Sally Sunshine at the Front Desk: “Well, that is not a problem. Our office is a member of ChiroHealthUSA, which entitles its members to a maximum initial visit fee of $150 . We can tell you about that and assist you with becoming a qualified member when you come into the office. Would morning or afternoon be better?”

And so it goes, and you will usually have no problem scheduling the appointment. Having a set fee for the initial visit that is legally discounted makes your new-patient scheduling so much easier than ever before. But when you have someone who has more questions, couple the procedure described above with an offer of a “Pre-Acceptance Interview” for maximum effectiveness.

An office can offer a pre-acceptance interview with a patient at no charge if this is a routine part of your initial visit procedure, if it is not advertised in public and if no evaluation or treatment is given. Often, a pre-acceptance interview is the best procedure for allowing patients to come in and find out if they are in the right place or are a good candidate for care, while avoiding any claim of financial inducement. In order to stay compliant, your office should have a written policy that declares the way you follow your policy as standard procedure for pre-acceptance interviews.

The pre-acceptance interview is an opportunity for the doctor to gather information about the patient’s condition and for the patient to learn more about the doctor, the doctor’s office and chiropractic care in general. During the pre-acceptance interview, it is vital that the patient has a clear and distinct opportunity to “opt in” and direct the doctor to move forward with any services before you move to CPT coded/charged services. After explaining the maximum initial-visit cap, if the patient is still not sure if they want to be treated by the doctor, there is a simple add-on to the previous script with Patty the Possible Patient.

Sally Sunshine at the Front Desk: “Well, Patty, I understand that you still have questions, but let me assure you, we offer an initial visit with the doctor called a Pre-Acceptance Interview, where you can fill out some healthcare information and discuss with the doctor the care in this office and whether you’re a good candidate for care. There is absolutely no charge for this interview, and rest assured, Dr. Jones won’t move forward with any billable services until you give your okay. Let’s get you scheduled, how does that sound?”

Once the patient comes in the office for the initial visit and fills out a history and intake form, the patient can be introduced to the doctor and the initial review can begin. Once the doctor gets a sense of what will be necessary for the patient, the doctor can say:

Dashing DC: “From what you’ve shared with me, I think you’re an excellent candidate for chiropractic care. In order to move forward from here, I’ll need to conduct a thorough history and evaluation, including an examination (and possible X-rays), to locate the underlying cause of your problem. Once that evaluation is complete, I can review the results and give you a report of my findings and what continued care would look like. As Sally discussed with you, these initial services are capped at $150 for our ChiroHealthUSA members. Are you ready to move forward?”

:dropcap_open: It is a responsible patient who takes into consideration their ability to pay and to follow through with care.:quoteleft_close:

Do not attach too much meaning if a patient ultimately says “No.” It is a responsible patient who takes into consideration their ability to pay and to follow through with care. Being gracious and understanding in this scenario may pay in spades later. The patient has now met the doctor and knows more about their care. It is unlikely they will go any place else once they decide to opt-in for care. If they do go elsewhere, and it is because the doctor offers discounts illegally or does not charge copayments, let it go; let them go. Hold your head high and know that you may have to get 10 “no’s” to get a single “yes.”

Using this process of capped fees and initial interviews is an excellent way to get someone to walk through your door. Remember, be aware of the potential for an inducement offense if the opt-in moment is not clear and defined to the patient, take the time to flawlessly follow your procedures for pre-acceptance interviews, and you will see an increase in new patients and community awareness of your office.

The Road to Financial Ease…Cash Profit Centers!!

:dropcap_open:R:dropcap_close:eimbursement woes are often at the forefront of chiropractic practices that rely heavily on patient insurance for payment. Many chiropractors find their cash flow dependent on the whims of insurance companies and their ever-changing reimbursement policies that bounce up and down like rubber balls. Trouble is – insurance companies seem to be “dropping the ball” more often lately when it comes to chiropractic care and many chiropractors are being hit hard by state legislation that negatively affects reimbursement.

So, how do you stay proactive, rather than reactive, in the face of all these income-impacting odds that are out of your control? Are there ways to maintain an “upper hand” in the face of the never-ending barrage of changes in managed care and third-party reimbursement?

:dropcap_open:It’s been reported that it costs a business 7-9 times more to acquire a new customer than to retain an existing one.:quoteleft_close:

Some chiropractic coaches and consultants may advise you to switch to a “cash-only” practice before it’s too late, and while this idea does have its merits, it certainly isn’t something that you can put into place tomorrow, next month, or even by the middle of next year. However, there are ways to transition your practice to cash that are relatively pain-free and that allow you to avoid the sting of constantly changing insurance regulations that take bigger and bigger bites from your reimbursement pie.

Remember the adage “Don’t put all your eggs in one basket?” Well that’s what you do when you count on insurance reimbursement to sustain your practice. You never seem to get ahead, even when you add new patients, because you are taking in with one hand and giving away with the other. And if it seems as though you can never catch up, you’re right, you can’t. That is…unless you make some changes.

Most patients’ policies allow for the reimbursement of critical care. Get them better and get them out. Better does not necessarily equate, however, to healthy and most chiropractors work with the goal of moving a patient from dis-ease and dys-function to health, wellness and optimal body function.

In order to stay ahead of regulatory and insurance changes, you need to transition your practice from a state of dis-ease (You do worry a lot, don’t you?) to a state of health and wellness.

Take a Look at Your Inactive Files

Come on, we all have them, and most of us have more than we care to share. What are you waiting for? Why didn’t those patients convert to wellness care?

In 2011, sales of wellness products and services reached $88 billion. Doctors of Chiropractic are better poised than any other class of professionals to direct the Wellness Revolution. It’s been reported that it costs a business 7-9 times more to acquire a new customer than to retain an existing one. The simple act of educating patients about the importance of wellness care and returning for care when needed can increase retention and create that wellness profit center that may be missing. An increase in your patient visit average brought about by wellness care can translate into thousands of dollars every month, outside the third–party reimbursement arena.

Increase Internal Cash Profit Centers

There are plenty of ways to increase profit centers within your practice and it’s a fact that practices that offer products and add-on services have higher gross revenues. Patients expect us to be whole body practitioners and, when necessary, this expectation creates cash profit centers that benefit the practice and services that help your patients stay healthy.

Here are some products and services that, when offered in your practice, can create buckets of incoming cash that are not dependent on the whims of third–party payers:

Nutrition – Provide nutritional counseling and supplements to enhance patient health. Even if you’re not a nutritional expert, you can find an easy-to-use line of products to recommend. The combination of office visits with a nutritional focus and the sale of nutritional supplements and refills can provide a big boost to your bottom line.

Pillows, belts, and car seats – Everyone needs a pillow. Why send them to Wal-Mart to buy one? If you subscribe to the philosophy that every neck patient in your practice would benefit from a cervical pillow, make it a part of your recommendations. The same goes for car seats for patients with low back pain.

Stabilizing Orthotics—We know that 90% of the population would benefit from Stabilizing Orthotics to enhance their treatment. Together with the ancillary services that are often covered by insurance, an average practice dispensing Stabilizing Orthotics to only 50% of new patients, can see increases of up to $50k in a year.

Massage Therapy – Did you know that Massage Envy, a massage therapy franchise, earned over $13 million in 2006, their first year in business, and many times that amount last year? Patients will pay cash for massage therapy. Make that available for your patients in your office, and tap into that profit center.

Pain Relief – Even at only $12-$15 per tube, items like Bio-Freeze or similar analgesics can really add up. Using the product correctly, a practice can increase revenue by as much as $8K per year.

Take Dr. X in Alaska, a doctor who recently contracted for onsite analysis and training. In one day, three patients were instructed to see “Sally” at the front desk to take a car seat, pillow, and belt. They left without receiving them because the communication between Sally and Dr. X was nil. Make these services part of the Report of Findings and patient treatment plan, and if the patient understands why they need the service, they are usually willing and able to follow your recommendations. Have your team members assist you with “eyes” at the front desk to ensure patient follow through. Demonstrate the connection between these products and services and the patient’s condition and care plan, and then you will be well on your way to increasing your revenues through profit centers that are valuable to your patient.

Medicare Is Not That Difficult!

:dropcap_open:T:dropcap_close:here is no area of reimbursement more confounding to doctors of chiropractic than Medicare. One of the major reasons for such confusion is the wide variety of opinions versus facts when it comes to Medicare compliance. Medicare has, perhaps, one of the most clearly documented sets of rules that must be followed. Interpretations of these rules are abundant, but the rules are clearly documented for easy understanding. Imagine my surprise when I got a call from a doctor who said he gave up on Medicare and just charges cash. Sounds good, doesn’t it? However, five months later and with over $100,000 in recouped Medicare denials in his pocket, this doctor began to see that Medicare is not really that difficult.

It seems the biggest reason chiropractors seek help with Medicare is that an office has had staff turnover and has found that the previous employee really was not doing the job they said they were, or the new employee is not performing at the level that was promised. With a lack of standard operating procedure and clearly documented systems, the train is bound to fall off the tracks.

In this case, a new employee began billing Medicare with no real training. Denials ensued, and she kept resubmitting. But with no clear knowledge of how to interpret the denials and without an understanding of what the denial reasons were, appeal after appeal was set aside. Three months later, the doctor quit billing Medicare and wrote off all the money. This one team member almost cost the office $100,000. Because the doctor was not paying attention to a few key principles for Medicare billing, he was within a few months of losing the reimbursement forever. Luckily, he was within the timely appeal and resubmission period. Here are some of the infractions that led to the doctor almost losing $100,000.

Medicare Will Not Pay an Adjustment Without the AT Modifier:

After the scathing Office of Inspector General’s Report of Findings on an audit of chiropractic billing and documentation, rules were set forth to assist offices with informing Medicare when the doctor believes that the care is acute or chronic in nature, and therefore, reimbursable. When an AT modifier is appended to the spinal CMT code, 98940-98942, it indicates to the carrier that the doctor believes it meets the definitions set forth for reimbursable care. If the adjustment code is missing the AT modifier, there must be some other indication, such as a GA modifier, which signifies that the doctor believes Medicare may not pay for this visit and that the patient has been notified. If the GA modifier is missing, there will not be sufficient evidence that the patient has been notified, Medicare will deny with a “contractual obligation” remark code, and the patient cannot be held responsible for the charge.

In this instance, the office failed to bill with the AT modifier. On more than half of the billing submitted, the AT was missing, and there was no indication that the patient had been notified before the treatment that they might be responsible for payment. For that reason, the denials on every visit came back with denial codes that prohibited the office from passing the charge along to the patient. And because the office team was not adept at reading these denial codes, they charged the patient anyway. This led to another incident of throwing up their hands and saying, “Medicare is just too hard.” In fact, using the AT modifier to indicate active treatment is one of the most basic tenants of Medicare billing. The AT modifier is a powerful tool; it alone will often dictate whether the care is reimbursable.

:quoteright_open:The AT modifier is a powerful tool; it alone will often dictate whether the care is reimbursable.:quoteright_close:

But the misuse of the code is like playing with fire. Most Medicare audits uncover billing that includes the AT modifier but does not meet the definitions of acute or chronic care. Incompetence, laziness, or miscommunication can lead to incorrect billing, such as leaving the AT modifier on a bill that did not warrant it. This is, unfortunately, abuse of the system. Do not leave the use of Medicare modifiers to team members. Doctors must drive this train and clearly identify on a visit-by-visit basis whether the care is acute or chronic, or if it meets Medicare’s maintenance definition.

If it is maintenance, do not bill with the AT modifier. Remove it to ensure the visit will not be considered for payment. Get the properly executed Advance Beneficiary Notice (ABN) signed and indicate that with the GA modifier on the CMT code, and the denial will come back with proper patient responsibility indicated. It is important to clearly understand Medicare’s definition of maintenance care for proper AT modifier usage: “The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.”

The Mistaken Belief That “If I Am a Cash Practice, I Don’t Have to Bill Medicare”
Not only is this a serious misconception regarding Medicare, but also it is extremely dangerous. Because other types of providers, like medical doctors, have options for opting out of Medicare, doctors of chiropractic feel that they should be able to do so as well. However, the Centers for Medicare and Medicaid Services (CMS) has made it very clear to providers that enrollment is mandatory. The following is an excerpt from a letter received directly from a Medicare carrier regarding this matter:

This letter is to inform you that once you have provided a coverable service to a Medicare beneficiary, you are bound by Medicare law. Centers for Medicare and Medicaid Services does not seek to limit or interfere with the right of the beneficiary to obtain medical care from the provider of his/her choice. However, once the physician has provided coverable care to a beneficiary who is enrolled in part V., the law (section 1848 (g)(4) (A) of the Social Security Act) requires that the provider/supplier submit a claim to Medicare; and in order to submit a valid claim to Medicare, the provider/supplier must enroll with the Medicare program.

For the doctor in question, there was no option simply to bill the patient and tell them that Medicare will not pay. Chiropractors, PTs in independent practice and OTs in independent practice have been deemed “non opt-out providers.” This means that they may not opt out of Medicare and must bill Medicare when a patient asks them to. The only true opt-out is when all Medicare patients are turned away and not treated for any coverable or excluded service in the Medicare program.

For this reason, when the bill is submitted to Medicare, it is with the expectation that it will be paid, and if it is not and an AT modifier was used, the office will be expected to follow through with the appeals process. If the office does not, it is tantamount to agreeing with the medical necessity denial, and it indicates that the billing was “just to see if it would be paid.” Be sure to bill for all CMT codes to Medicare, including acute, chronic and maintenance visits. For maintenance visits, if the patient indicates on the ABN form (by selecting Option 2) that they do not wish their care provider to bill it, that relieves the chiropractor of the responsibility, and the patient can be charged.

This office caught the errors and problems before the time limit for filing appeals expired. It is vital that offices set up standard operating procedure for billing and processing Medicare. It is a key part of the billing and collections system and comes with a set of benchmarks that must be followed exactly. Medicare really is not that hard, and in some cases, can be one of the most reliable payers when compared to others. Follow the rules, write a standard operating procedure, and enjoy Medicare reimbursement that is healthy and consistent.

The Hot and Cold of It

:dropcap_open:D:dropcap_close:r. X has been in practice for more than 25 years. As a beloved and trusted practitioner in his town, his patient database bulges with past and present patients. Because the office is in a rural community, patients include farmers and ranchers, retirees, and some families. They were used to coming in for care when it was needed, and didn’t much believe in that “maintenance care”. Imagine his surprise when the audit letter came in from Aetna Insurance, asking for 10 of his patient files. He dutifully copied all the records, sent them in, and felt pretty good about the potential outcome, since he felt he was a “pretty good documenter”. The next correspondence from Aetna nearly knocked him off his chair.

Dr. X had a set protocol he followed on everyone. Along with chiropractic manipulations, patients received ice and electric muscle stimulation during the first few weeks of care, and then heat and muscle stimulation for the rest of the treatment episode. Sometimes, these episodes went on for as many as 6 months. No active care or other services were rendered in the office. Dr. X confided to me that he always felt a practice like this just flew under the radar, since surely his care was not the problem of insurance gouging. He quickly learned that the third-party world saw things differently than he did.

Aetna asked for nearly $35,000 back. Surely this could not be the result of review of only these 10 charts! Aetna used a procedure called “extrapolation” where the actual discrepancies were calculated, and the multiplied across the entire classification of Aetna insureds that had been paid to this doctor over the prior three years. Here was the breakdown:

$13,500 in 97010 (hot and/or cold packs) billing that was deemed “not medically necessary”
$12,500 in 97014 (electric muscle stimulation) that was deemed “not medically necessary”
$4,000 in 99213 (established patient evaluation and management) that was denied as an unbundled service

The Protocols Failed the Doctor

97010, hot/cold packs, is often a necessary service. In fact, it is the position of the American Chiropractic Association that “the work of hot/cold packs as described by CPT code 97010 is not included in the CMT codes 98940-43 in instances when moist heat or cryotherapy is medically necessary in order to achieve a specific physiological effect that is thought to be beneficial to the patient. Indications for the application of moist heat include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation, and increase in lymph flow to the area. Indications for the application of cryotherapy include, but are not limited to, relaxation of muscle spasticity, induction of local analgesia and general sedation, promotion of vasodilation, and increase of lymph flow to the area.” The doctor believed that these reasons were why the patient was receiving these services, but the documentation didn’t continue to show the medical necessity for ongoing ice/heat in the office, along with the manipulations. Nothing in the patient’s record indicated on a daily basis that the ice/heat was being used for any of these things. Dr. X thought that explaining this once in the beginning of care, in the treatment plan, was enough. The same problems existed with the electric muscle stimulation, and the documentation deficits were similar. He had no choice but to reimburse the carrier for these amounts and try to do better going forward.

How Do We Improve This Situation?

Medicare made the decision in 1996 that 97010 would be considered a “bundled” service for all provider types and not reimbursable. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance it means code 97010 is not a separately billable service when rendered to a Medicare patient. It is considered a part of whatever primary service is rendered to the patient; either CMT code 98940, 98941, or 98942. This is different than a “non-covered” service, which can be charged to the patient. A bundled service cannot be charged to the patient, as it is being reimbursed within another code’s value. Many private and commercial carriers have taken on the same policies and definitions of medical necessity. Therefore, it’s important that you set a protocol for 97010 usage in your office that meets the guidelines for the carriers you’re working with, and where efficacy of the outcomes of 97010 can easily be documented in your patient’s record.

Try these procedures and protocols to help justify your prescription for ice/heat in the office for your patients:

Clearly document the physiological effect you expect to gain from the 97010 service, whether heat or ice, in your treatment goals. Goals are not just for your adjustments. Goals are for every service you order for the patient.
Be realistic about the length of time into the episode of care that you will continue to render this heat/ice service in the office. Unfortunately, the evidence based practice of heat and cold modalities is limited and the knowledge is purely empirical. This knowledge dictates that ice therapy is used during an acute phase of treatment. If you are using ice beyond this phase, clearly document the reasons why. Likewise, heat therapy has excellent uses as the patient is returning to normal function, and preparing for active care in the office. Be reasonable about what levels of this care must be performed in the office and what can be transferred to home care, after careful training and explanation.
During the active use of heat/cold therapy during the episode of care, continue to comment in your daily treatment notes about the continued efficacy of the modalities you’re using. Remember to comment in this way: “The patient is improving and I know this because…” and “The patient needs more care (hot/cold) and I know this because…”. This will assist you with the practical explanations of the necessity of this care.

As a clinician, only you know what the patient really needs. You are the custodian of those health care dollars because you indicate the medical necessity of the care with your signature on the billing form. Don’t get stuck in outdated practices and protocols that haven’t been updated in years. The use of treatment protocols is excellent, and they can be a tremendous tool in your treatment planning and execution. Just be sure that the protocols you’re using are easily discernible and defendable should you wind up on the wrong end of a $35,000 recoupment letter.

Kathy Mills Chang is a Certified Medical Compliance Specialist(MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at (855) TEAM KMC or [email protected]

Medical Review Policy Is Your Friend

:dropcap_open:I:dropcap_close:t’s the kind of phone call no doctor wants to receive. This particular doctor vaguely remembered the representative from the insurance carrier asking questions several months ago about some of the procedures performed in the office. She also vaguely remembered a request for some charts from this same carrier. Now, on the phone, she was being told that more charts would have to be reviewed and it didn’t look good. “How can this be?” she wondered out loud. “I’ve been getting paid properly, had no red-flags, and didn’t even know there was a problem,” she further mused. What was about to unfold seemed too unbelievable, and yet it was happening in living color.

The reimbursement request was a simple letter on carrier letterhead. It laid out in detail all of the billing and coding violations they felt this doctor had committed. This company used a process called “extrapolation”. They performed some mathematical equations. The determination was that if the chiropractor made these errors on this group of reviewed files, then the insurance carrier could calculate errors in ALL the services in these categories provided over the last four years. If we apply this math, including the amount of money paid for these services over time, multiplied by the error rate, the doctor was getting a bill for several hundred thousand dollars! I know, right?? Holy Cow!

Fortunately, this doctor’s malpractice insurance had a clause for audit coverage within the policy. She was grateful because this coverage provided for her attorney’s fees and costs. Now she felt that she had some support in fighting the system. We rolled up our sleeves as a team and began looking at the allegations. Here is a list of some of the concerns:

1. The office provided massage therapy and it was delegated to a licensed massage therapist. Because it was not performed by the doctor all of the payment for the services had to be refunded.

2. Several therapy procedures, like electric muscle stimulation and traction, were also in question, based on the type or location of service.

3. Evaluation and management services were billed on the same date as chiropractic manipulative treatment services. Although this was only periodically, obviously for real examinations, the carrier felt there should be no coverage.

Wait a minute! Who sets these rules? How’s the doctor supposed to know about these rules? Doesn’t my state scope of practice allow me the opportunity to delegate services to properly trained individuals? As you can imagine, all of these questions went through our doctor’s mind. We found the answer in the medical review policy located on the carrier’s website. This particular carrier clearly indicated that massage therapy was a covered service, but was not covered when it was rendered by someone other than the chiropractor.

Because the services had been delegated, the carrier felt it was appropriate to ask for a refund of all of these payments. The electric muscle stimulation policy was also located on the website. Although this is a seemingly ridiculous policy, and in fact it was changed shortly after this audit took place, it did say that 97014 was only covered in an inpatient setting. The evaluation and management services issue was easily refuted. There is tremendous information available through the American Chiropractic Association and other coding authorities that have allowed us to educate this carrier on what’s appropriate.

This doctor’s woes are not quite over yet, as the case is ongoing. There is much review that needs to be accomplished. Can you be sure that you could pass such an audit? It is imperative that each and every chiropractic practice clearly understands the agreements that have been made when participating in a managed care or preferred provider organization. Even in an out-of-network situation, medical review policy must be followed. Simple online or telephone verification techniques are not enough anymore. The following processes should be included in every office’s standard operating procedure for billing compliance verification:

1. Review your provider agreements with every organization that you participate with. Look for specific language that rules coverage, tells you who can provide what services and offers medical necessity definitions and other particulars.

2. Study the medical review policies on the carrier’s website that govern the various services that you provide in your office. You can often search by code or by specialty. If you provide traction with a roller table, for instance, make sure that it isn’t specifically excluded under the policy. And if it is, find out if you are allowed to do it and charge the patient cash! This may also be forbidden.

3. Double-check the national coding policy for the most common services you render to be sure you’re spot on with your documentation of medical necessity. Be ready to appeal or defend denials that don’t make sense. You deserve to be paid for what you do, as long as it meets the guidelines you’ve agreed to by policy or by contract.

:quoteright_open:Double-check your malpractice insurance to be sure that you have coverage available should you be audited.:quoteright_close:

We can all use a nudge, a reminder, or a wakeup call to avoid the status quo. Remember, when you’re billing a third party payer for services in the office, they get to dictate, to a large degree, the level of reimbursement. When you receive denials for medical necessity, remember that you must appeal them. Otherwise it appears that you are in agreement with their denial. Double-check your malpractice insurance to be sure that you have coverage available should you be audited. Don’t live in fear! Be prepared! He who has the most information wins!

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at 888-659-8777 or [email protected]

You Mean I Can’t Jack My Fees Just Because It’s PIP?

Because I get so many unusual questions, I really should not have been surprised by this one. After all, many doctors believe that it is perfectly acceptable to have different fee schedules for different kinds of patients. As I asked questions, and learned more about them, it seemed this practice had what they called a “time of service discount”. If a patient is without insurance coverage at all, this discounted fee schedule applied to you. For an initial visit in the office, if you had insurance, the fee was around $350.

Of course, this included the initial exam, x-rays, and treatment. But if you were without insurance, this magic discount appeared and you were charged $125. That’s what I call a discount! Apparently this worked great for them…until they were targeted by an insurance company. An investigator was dispatched, posing as a new patient. This investigator represented himself as a cash paying patient without insurance from the first phone call through the initial visit with the doctor.

The CA dutifully explained the “time of service discount” fee to the patient at checkout, since they were without insurance. She quoted $125 for all the x-rays, examination, and treatment. As this patient was checking out, he told the front desk assistant that he thought this may be the result of a car accident. He handed over an adjuster’s name and information, and the CA told him to hold off on paying, until this could be verified. Next visit, the patient was given the GREAT news! There was truly a claim open, and he wouldn’t have to worry about paying. It would all be submitted to the carrier. Can you guess what happened next?

:dropcap_open:The assistant was on hidden camera talking about the time of service discount, and then, because this was now being billed to a carrier, the price went up $225.:quoteleft_close:
This was a set up. When the office submitted the bill for the full fee of $350, the carrier had the proof they needed that something fishy was going on. The assistant was on hidden camera talking about the time of service discount, and then, because this was now being billed to a carrier, the price went up $225. A formal investigation was opened, with referral to the Attorney General in his state, and the Board of Chiropractic Examiners. So, is it ok to give a time of service discount or not? A simple yes or no would be nice.

Unfortunately, it depends on whom you ask, what state you practice in, if the patient is federally insured, AND their particular circumstances. In the days before insurance, third party reimbursement, state and federal payers, nobody was really paying attention. Now, when someone else is paying part or all of the costs for health care, and especially under a regulated program like Personal Injury Protection, rules change and regulations apply.

Dual fee schedules (charging more to insurance companies than you do to your cash patients) and improper time of service discounts (reductions that are really MORE than a reasonable bookkeeping reduction) are illegal in most states. Offering discounts that do not fall into one of Medicare’s safe harbors is absolutely a violation of federal regulations in EVERY state. Personal Injury Protection in this doctor’s state included a regulated fee schedule. Some include a “most favored nation” clause, like Medicare does. It says that you will not charge any patient “significantly less” than Medicare. If your PIP law has such a clause, offering discounted fees below this amount to cash paying patients is clearly a violation.

:quoteright_open:It even works with partially insured patients, like those with Medicare. :quoteright_close:
All is not lost, however. Once we helped this office get through the investigation and aftermath, we assisted them with setting up a legal cash discount fee schedule. This applies to anyone paying cash, even Medicare patients who pay for the non-covered services. It’s my opinion that the cleanest, most logical and ethical way to meet and exceed the requirements of legal discounting, allowing you to accept a lower than normal fee, is to join a Discount Medical Plan Organization (DMPO). When a patient also joins, that makes a legal contract within which you can have a set fee schedule, not unlike insurance! Using a DMPO, you can still bill your UCR fees and have the protection of a contract that allows you to offer network-based discounts to your cash and underinsured patients.

It even works with partially insured patients, like those with Medicare. I encourage all of my clients to join, rather than to worry about whether the various “deals” they make are ok. By belonging to a DMPO, such as ChiroHealthUSA, all of your worries about illegal discounts can go away. If only my client had known about this before this nightmare landed on his doorstep! Luckily, it’s not too late for you to tune up your fee schedules and avoid the unpleasant results of dual fee schedules.

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and since 1983, has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at 888-659-8777 or [email protected]

Why Do I Have to Learn E/M Documentation Guidelines?

:dropcap_open:T:dropcap_close:his particular Blue Cross Blue Shield carrier has been known to cause heartburn for doctors of chiropractic for quite some time. When I received the phone call from a doctor in that state who had been referred by a friend of a friend, I wasn’t surprised by what he told me. This Blue Cross Blue Shield carrier audited 20 of his files. Not surprisingly, in all 20 cases they determined that, based on his documentation, his initial visit Evaluation and Management code needed to be down coded one level. They were asking for quite a bit of money back. The deadline for appeal was a few short days away. He had not taken the letter as seriously as he should have and was now up against the wall. After looking at a few samples of the documentation for these patients, I felt that the doctor had some chance to defend himself against the reimbursement request. The bigger concern for both of us was—if the doctor did not appeal the decision—this carrier is known for extrapolating. Extrapolation means that they take the percentage of errors found in the 20 files and apply it to the total number of patients paid over a period of years. Since they found errors in 100% of the cases, he ran the risk of this carrier asking for a refund on every Evaluation and Management code they ever paid to this doctor. We had to do something. Surely, his documentation was not that bad.

:dropcap_open:Unfortunately, the electronic documentation software used in the practice did not serve the doctor very well.:quoteleft_close:

We agreed to review all 20 files that the carrier reviewed. Unfortunately, the electronic documentation software used in the practice did not serve the doctor very well. His intake form that the patient filled out was insufficient to meet even the most basic obligations. This was exacerbated by the fact that the doctor was completely unaware of the requirements of selecting the correct evaluation and management code. There was very little in the way of good news about this audit.

Because this doctor was also quite “old school”, he did your run-of-the-mill, basic chiropractic examination, which had a number of holes in it when compared to documentation guidelines. In the musculoskeletal specialty examination requirements, four of the most basic requirements include:

Inspection, percussion and/or palpation with notation of any misalignment, inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture
Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Even though there are many other systems included with this examination, such as basic findings in the areas of skin, neurological, cardiovascular, constitutional, and lymphatic, the most basic of musculoskeletal findings can be included in even your most run-of-the-mill chiropractic exam. The problem in his case was that the documentation software didn’t provide for him the most fundamental of templates to include these important requirements. He documented with words like “fixations”, “taut and tender fibers”, and “postural analysis”. When I questioned this doctor about the notes, it was clear he DID the work. It was not documented properly, or he did not use words that auditors from BC/BS recognized, so he got NO credit for the work he did.

To see the actual checklist Medicare auditors fill in when going through a practice, go to http://tinyurl.com/7xk6o9a, and click on the audit tool for EM services used by Medicare.

:quoteright_open:A few easy tweaks of his documentation software, standard operating procedures, and terminology set this doctor on the right track.:quoteright_close:

A few easy tweaks of his documentation software, standard operating procedures, and terminology set this doctor on the right track. Let’s hope you don’t find yourself with an audit letter from BCBS; but if you do, you’ll be much more confident knowing a few important things:

Know the EM documentation guidelines. Make sure that your electronic notes software or your paperwork aligns with these guidelines point by point to give you peace of mind.
Periodically pull the last five new patient files and do a self-audit to confirm if the EM code you selected will pass muster in an audit.
If the carriers you deal with publish chiropractic guidelines, make sure you’ve read them, along with any medical review policy, and include them in your compliance policy. This way, you’re proactively following the rules, and can feel confident that your efforts are in line with expectations.

Believe it or not, this audit was a good thing for this doctor. Our appeal was accepted and he didn’t have to pay back any monies, since he could demonstrate his willingness to improve his documentation and recordkeeping. He’s now well on the way to sleeping better at night, knowing that he is proactively compliant. Better documentation, better compliance and a good night’s sleep!

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and since 1983 has been providing chiropractors with hands-on training, advice and tools to improve the financial performance of their practices. In 2007, KMC University was created to streamline, develop and offer a broader range of chiropractic solutions in the areas of coding, insurance, patient financial procedures, Medicare and compliance. Kathy can be reached at 888-659-8777 or [email protected].

Doc in the Dark

:dropcap_open:I:dropcap_close: had four messages waiting when I returned from lunch. I’d only been out of the office for a couple of hours, so I was surprised they were all from the same doctor. I could tell right away there was increasing urgency in the doctor’s voice and that he was extremely agitated. Earlier that morning, he unraveled the puzzling events he’d been bewildered by for months. It seemed that a trusted team member was falsifying billing and probably embezzling. He flip-flopped between feeling guilty that he hadn’t been more on top of things and feeling furious over this horrible breach of trust. Where to begin? How deep did this dirty deed go? Unfortunately, when my team and I started digging, it was hip deep. There were services billed that were not performed, money collected that was not theirs, and some money that was completely unaccounted for, and, I feared, stolen. What we have here is both a reimbursement problem AND a compliance problem.

In this case, an onsite visit made the most sense. There was such a mess and a new team member had to be trained. After spending two days deeply involved in analysis and training, I have to say my heart aches for this doctor. He knows where he was culpable…he wasn’t paying attention. He handed over the insurance department to her, rather than delegating it. He didn’t know she was padding bills, hiding money, and having checks re-routed to her home. He didn’t know because he lacked the accountability systems in the practice, and…he wasn’t paying attention. I get fighting mad when I find doctors that have so much trust in their CAs that they simply accept their word as gospel truth. Even if I was your Insurance CA, you need systems.

Unfortunately, this incident crossed the line into a compliance nightmare, because insurance companies were billed as though they were correct services, when in fact they weren’t. And guess whose name was signed to line 31 of the 1500 billing form? The doctor. Once the carriers began investigating, they couldn’t be sure the doctor wasn’t involved. That opened an entirely different can of worms for that doctor. Imagine the devastation he felt! Betrayed by a team member/friend/fellow church member, and then blamed for the heinous act.

I hope you never find yourself in such a situation. But if you do, know what to do about it. Here are some tips:

Have competent staff; trustworthy staff. But remember, this is your livelihood and your income. Doctors should strive to learn all they can about billing and collections. Know enough to manage them, ask the right questions, and get reports so it appears you are in the game.

Implement systems that allow for checks and balances. A simple end-of-day balancing form was put into service that forced the CA to total money, routing slips, and patients, and balance to the penny. Those were reviewed by a third party, and then turned in to the doctor. Not fool-proof, but markedly better than nothing. Other compliance related activities were easy to implement for peace of mind.

If you find that overpayments have been received, or embezzlement has happened, you have a very short time to refund the money. In the case of Medicare, only 60 days. That means you should be self-auditing on a regular basis. The OIG Compliance rules say you have to. Don’t leave this to chance. You don’t want to find out something is amiss only after you’re audited by an outside source. Self-auditing and self-reporting are a much better plan.

Our staff can be like family, and rightly so. It’s easy to be lulled into a false sense of security. Systems, compliance programs and checks and balances installed in the practice will help to make sure you never have to suffer this unspeakable nightmare.