Consistent Core Compliance = Really Regular Reimbursement

Whether your office has been open for more than 20 years, or you are about to hang your first shingle, consistency, systems, and accurate compliance should be your watchwords. Many doctors zone out when the word compliance is thrown around. There are several reasons for this, including it’s complicated, overwhelming and, most of all, confusing. However, when we are building a strong office, the strength of your foundation can only be as strong as your compliance measures. A new practitioner would be wise to mix these compliance components in the cement that will hold the practice together. Additionally, any doctor considering opening a satellite office must insist that the systems used in one office are seamlessly duplicated into the new office. Let’s discuss the most critical morsels of information that every chiropractic office must ensure are implemented. Remember, because treating Medicare patients in an office causes you to be accountable to all the rules of compliance we are talking about here, these rules often spill over to every kind of financial encounter in your office. Review this list and appraise your level of compliance on these important processes that must be implemented in your office. If you find any weaknesses in your systems, confusion in your understanding of the rules, or concern that you may not be completely compliant, act now to get it corrected. That will allow you to sleep at night and put your concentration where it should be, on helping more people with the power of Chiropractic care.

1) To Join or Not to Join: If you plan to dwell on any level in the land of third party reimbursement, whether Medicare, commercial health insurance, or personal injury, be sure you clearly understand whether being in or out of network is your best choice. As a new practitioner, you may think it’s imperative that you scramble to join every major insurance network that your patients could potentially belong to. It’s easy to make the incorrect assumption that patients will only come into your office if you participate on this network. There are many things to consider before joining a network. Among them are the levels of reimbursement you can expect, the restrictions placed on the practitioner’s ability to balance bill the patient, and the definitions they will apply to your treatment from their medical review policy. You must read your provider’s agreement and understand every stipulation that you are agreeing to with your signature. Far too often, doctors find out well after the fact, that a procedure regularly performed in the practice is not covered or bundled per the contract. Additionally, providers may choose to add a new service or product, such as spinal pelvic stabilizers, and find that their provider agreement allows for reimbursement in the fee schedule at a level lower than the cost of the product. If you plan to join a network, be sure that you every rule of the agreement that you signed.

2) Know How to Define Medical Necessity: If you are dealing with third-party payers, one of the most important building blocks of compliance is to understand their definition of medical necessity. To fully and clearly apply these principles in your practice, you must be clear on the difference between what is clinically appropriate in your mind and what your carrier believes is medically necessary. Most often this definition is in writing somewhere. For example, with Medicare, it is clearly laid out in the Local Coverage Document from your Medicare carrier. The definitions of acute, chronic, and maintenance care, and for medical necessity, can be the most important information in your toolbox. Insure that you are only submitting billing that is clearly in line with both your agreement and the medical review policy of the carrier. Of course, if there is a discrepancy, they will not try to tell you that you can’t treat the patient but, rather, dictate that they expect the patient to cover the cost of the service out of pocket.

3) Never Give Away Services: Never discount or give away a service unless you’ve met the safe harbors. Safe harbors can include legal hardship agreements or discounting within the contract of a Discount Medical Plan Organization (DMPO), such as ChiroHealth USA. Regardless of what you may think your state law says, never discount or induce patients with free services for any Federal program. This includes Medicare and health insurance like Mail Handlers and the Federal Blue Cross Blue Shield program. Additionally, you may be surprised when you go to research what your actual state law says about discounting. Many doctors incorrectly assume they are allowed to offer generous time of service discounts when, in fact, nothing could be further from the truth. For consistency, joining a DMPO alleviates all concerns because you are now protected within the safe harbor of a contract.

4) Compile Office Standard Operating Procedure (SOP): One of the greatest protections to a practice is written operating procedure. From a compliance standpoint, your written policy and procedure manual contains your declaration of the way you intend to follow the rules in your practice. From a practical point of view, this manual details every procedure performed in the practice. If a team member leaves, all of your institutional knowledge does not walk out the door with them. Rather, the written detail of how your practice runs, down to the step-by-step procedure for entering a patient payment, is safely tucked away in your procedure manual for anyone to follow. With this important manual in place, any deviation from it could be seen as an error, rather than a pattern of abuse. For this reason, new practitioners must begin compiling this important manual immediately. Those who plan to open a satellite office should make sure that their original office is fully operational with procedures in writing before ever attempting to open another office. This ensures consistency and compliance.

It’s easy to tune out when the subject of compliance is brought up. However, looking at this important topic in the right light is vital, because its impact on your reimbursement is extraordinary. Whether a new practitioner, or a seasoned veteran, following the rules most often nets your practice more money. This increase could be seen on the front end from increased reimbursement due to your excellent procedures, or on the back end from getting to keep your money rather than have it recouped due to errors. Bulletproof your practice with excellent procedures and knowledge of reimbursement rules and regulations and you’ll find smooth sailing that you can take all the way to the bank.


Kathy Mills Chang is celebrating her 27th year serving the chiropractic profession. She is the founder of her own Reimbursement consulting firm. Her company has a clear goal: Helping Chiropractors make and keep more money. If you’d like to learn more about this service, or complete a no-charge reimbursement consultation, contact 1-888-659-8777 or email [email protected].

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