March 2014c.ymcdn.com/sites/ · 1-855-TEAM KMC (832-6562) 3 ... • No Policies and SOP – Ignored help when notified of OIG concerns Denial In The Face Of Adversity • This doctor

www.kmcuniversity.com March 2014

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Six Secrets Every CA Needs to Know to Rock Their Practice

Finances and RetentionKathy Mills Chang, MCS-P

The KMCU Way

• Systems that haveworked 30+ years

• Basics are often themost missing items

• Training is thefoundation

• Training andrepeating thattraining, and roleplaying make masters

Protect Your Practice with Innovative Risk Management

Techniques

Ch-Ch-Ch-Ch-Changes• Healthcare has

been changing for awhile

• The changes aregetting more rapidand are hittingcloser to home

• That is evident withthe followingaccount of a DC andhis story…

Chiropractic and the OIG• For the first time since

May 2010, the Officeof Inspector General,of the Dept. of Healthand Human Services,has published areport specificallyabout chiropractic...orrather, onechiropractor inparticular.

OIG Report Facts

• This fellowchiropractor’s diresituation representsthe current state ofrisk that mostchiropractors are noteven aware they faceon a daily basis.

• Is this you?


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Audit: Efficiency Check; A systematic check or assessment,

especially of the efficiency or effectiveness of an organization or process, typically carried out by an

independent assessor

What Does This Mean?

• Records requests come in all shapes and sizes

• Sometimes they are a “probe”

• Sometimes they are a “system”

• Sometimes they are what they are

Who’s Asking??• Commercial

insurance Carrier• Personal Injury

Carrier or Adjuster• Worker’s

Compensation Carrier or Adjuster

• Medicare Administrative Contractor (MAC)

• Recovery Audit Contractor (RAC)

• Comprehensive Error Rate Testing (CERT)

• Zone Program Integrity Contractor (ZPIC)

• Program Safeguard Contractor (PSC

Why Are They Asking??• Prepayment review of claims always results in an "initial

determination'' • Post-payment review may result in no change to the initial

payment to the provider or may result in a "revised determination" that would require the provider to pay back monies for services determined to be "not reasonable or necessary."

• Automatic, or non-complex, reviews occur without clinical review of medical documentation submitted by the provider, such as in cases of medically unlikely edits (MUEs) or when there is no timely response to an audit request letter.

• Complex reviews involve requesting, receiving, and medical review of additional documentation associated with a claim.

What’s Their Motivation?• Payment

Recovery/Recoupment• An overpayment occurs

when a provider receives excess payment due to– duplicate submission of the

same service or claim,– payment to the incorrect

payee,– payment for excluded or

medically unnecessary services, or

– a pattern of furnishing and billing for excessive or non-covered services, as determined in an audit or review.

What’s Their Motivation?

In 2010, President Obama announced the following three goals for cutting improper Medicare payments by 2012:

– reducing overall payment errors by $50 billion

– cutting the Medicare fee-for-service error rate in half

– recovering $2 billion in improper payments


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They Look For…

• Coding Errors and Patterns

• Review Outliers• Review of high dollar

codes-BCBSIL SO’s• Identify Fraud and

Abuse • This is JOB ONE!

What Might Be the Trigger?• Overutilization• New carrier—pre-

existing condition• Unusual codes• Unusual errors• Billing errors, like lack

of Box 14 changing• Your number came up

Cautionary Tale• Because we

understand the critical nature of the situation…

• KMC University is making this information available to the entire profession, to raise awareness of what must be done to steer clear of consequences this doctor faces.

What Happened? • Inquiring Minds…:

– Why this doctor was on the radar

– The specific issues that were non-compliant

– What the OIG did– What you can do to

make sure YOU do not wind up in this situation

– If you do wind up there, what to do about it

What This Doctor Didn’t Know That He Didn’t Know!

• The $708,000 recoupment finding to Medicare:– Ignorance of the rules

• Upcoding charges• Billing Medicare

inappropriately• Poor documentation• No Policies and SOP

– Ignored help when notified of OIG concerns

Denial In The Face Of Adversity

• This doctor reached out for help when the original OIG letter came in. A review was done, and it was very obvious there were many problems.

• "Oh, it's too expensive to have you help me, and I don't need a lawyer".


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Timely Action Steps

• Timely action steps carry big value…to the OIG

• Define the problem• Get help to correct

your mistakes, to learn and train and take specific actions to change your behaviors

OIG Report Facts• The OIG is not “out to

get us all”• There is enough “low

hanging fruit” to take care of the federal budget deficit

• Be aware of the specific errors pointed out in the report

Size Matters

• This doctor was in the top 5 in the entire country for volume of CMT codes billed. Top 5!!!!

• He billed an outrageous percentage of 98942, all 5 spinal regions!

So? I’m a Full Spine Adjuster!

• Medical necessity definition dictates that you must prioritize each area of complaint

• Every visit:– S + O (P + ART) for

every region treated– 2 DX codes for each

region– Treatment plan for

each/short and long term goals

Why It LOOKS Fishy… The Guideline and Expectation“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 patients condition and provide reasonable expectation of recovery or improvement of function.”


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Understand the Rules

• He ONLY billed AT modifier, never ever moving a patient to maintenance care.

• Even in the details of the rebuttal from his attorney, he also argued that he "never delivered care that was not AT Modifier worthy".

GA Modifier

Is All Care Medically Necessary?

Clinically Appropriate Care

• Life enhancing• Symptom relieving• Wellness care• Supportive care• Maintenance care

Medically Necessary Care

• Yields a significant

improvement in clinical

findings and patient

functionality.

MaintenanceCMS defines Maintenance Therapy as: "Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy."

Episodes of Care• The foundation for an

episode is contained in the beginning four steps of documentation.

• There was confusion about what an episode of care is

• Therefore, the documentation necessary was NOT present

Blatant Disregard• Medicare

documentation requirements are published.

• We, as doctors, must know how to diagnose, treat in episodes of care and dismiss patients from active treatment.

• Have written policies and procedures.


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Any Patients in Your Office in this Circumstance?

Medically Necessary Care

Clinically Appropriate Care

You Are The Doctor• He tried to blame his

software for not allowing enough Diagnosis codes.

• EHR software is simply a mechanism, a tool.

• Just because you have it, that doesn't mean that it will do your job as a doctor!

Exact OIG Recommendations• Refund $708,022 to the

Federal Government and

• Establish adequate policies and procedures to ensure that chiropractic services billed to Medicare are medically necessary, correctly coded, and adequately documented.

Extrapolation at Its Finest Sure, let me just get my checkbook!


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They Talked to Patients OIG Strategic Plan 2014-2018The OIG has a clear an narrow focus for success over the next 4 years:

• Goal One: Fight Fraud, Waste, and Abuse • Goal Two: Promote Quality, Safety, and

Value• Goal Three: Secure the Future • Goal Four: Advance Excellence and

Innovation

Goal One: Fight Fraud, Waste, and Abuse

• Critical to OIG’s mission is fighting fraud, waste, and abuse. We will continue to employ a multi-faceted approach of prevention, detection, and deterrence.– Identify, investigate, and take action when needed– Hold wrongdoers accountable and maximize

recovery of public funds– Prevent and deter fraud, waste, and abuse

What can you learn from our Work Plan? (says the OIG)

The OIG Work Plan outlines our current focus areas and states the primary objectives of each project. The word “new” after a project title indicates the project did not appear in the previous Work Plan. At the end of each project description, we provide the internal identification code for the review (if a number has been assigned), the year in which we expect one or more reports to be issued as a result of the review, and whether the work was in progress at the start of the fiscal year or is planned as a new start.

Chiropractic services — Portfolio report on Medicare Part B payments (new)

Billing and Payments. We will compile the results of prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities.

Context—Prior OIG work identified inappropriate payments for chiropractic services that were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent.

Chiropractic services — Portfolio report on Medicare Part B payments (new)

Medicare does not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” (Social Security Act, §1862(a)(1)(A).)

This planned portfolio document will offer new recommendations to improve Medicare chiropractic vulnerabilities detected in prior OIG work. (OAS; OIG-12-14-03; expected issue date: FY 2014; work in progress)


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We’ve Been Hearing This Since 2006

Chiropractic services—Part B payments for noncovered services

Billing and Payments. We will review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements.

Context—Prior OIG work identified inappropriate payments for chiropractic services furnished during calendar year (CY) 2006. Subsequent OIG work (CY 2013) also identified unallowable.

Chiropractic services—Part B payments for noncovered services

Part B pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. (42 CFR § 410.21(b).) Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. (CMS's Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 30.5B.) Medicare will not pay for items or services that are “not reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) (OAS; W-00-12-35606; W-00-13-35606; various reviews; expected issue date: FY 2014; work in progress)

Chiropractic services—Questionable billing and maintenance therapy (new)

Billing and Payments. We will determine the extent of questionable billing for chiropractic services. We will also identify trends suggestive of maintenance therapy billing.

Context—Previous OIG work has demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including recent work that identified a chiropractor with a 93-percent claim error rate and inappropriate Medicare payments of about $700,000.

Chiropractic services—Questionable billing and maintenance therapy (new)

Although chiropractors may submit claims for any number of services, Medicare reimburses claims only for manual manipulations or treatment of subluxations of the spine that provides "a reasonable expectation of recovery or improvement of function." Moreover, Medicare does not reimburse for chiropractic maintenance therapy. (CMS’s Medicare Benefit Policy Manual, Pub. No. 100 02, ch. 15, §30.5B.) (OEI; 01-14-00200; expected issue date: FY 2015, work in progress)

Don’t Learn the Hard Way!• The simple steps that

could have been taken to avoid this nightmare

• How expensive was his inaction?

• $708K back to the government, and probably losing Medicare privileges!

• Don’t let this be YOU!


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A Warning the Should be Heeded The 7 Steps of the OIG Compliance Program

The purpose of a compliance program is:

• To integrate policies and procedures into the physician’s practice that are necessary to promote adherence to federal and state laws and statutes and regulations applicable to the delivery of healthcare services.

Is it Mandatory?• Came out of the

sentencing guidelines• Affordable Care Act:

Mandatory Compliance Plans Coming Soon

• CMS has NOT finalized the requirements

• CMS will advance specific proposals at some point in the future

• The truth is, we've been being told that since 2001.

• Get your policies and procedures and OIG compliance plan in place.

• It's too easy to do, and if you don't know how, ask us! We teach this every weekend!! Don't delay.

Just Do it! Compliance Program! Responding to Records Requests


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Lack of Medical Necessity

• Does your documentation tell a believable clinical story that makes sense as to why you are still treating and why you should get paid?

Why Denials Occur• Administrative

– Incorrect ID number– Incorrect vital

information of primary holder, patient, etc.

• Unsupported code– Therapy codes– Exam codes

• Medical necessity isn’t supported

What if Info is Missing?• Don’t try to cram it in

after the fact• Summarize with a

cover sheet style “Case Summary”

• Explain the detail that might have been left out

• Hope that they will add it to the record as an addendum, dated by you

Avoiding HIPAA Privacy mistakes

Minimum Necessary Standard• The minimum

necessary standard requires you to evaluate your practices and enhance any safeguards as needed to avoid and limit unnecessary or inappropriate access to and disclosure of PHI.

Identify the Internal and External Risks of Disclosure of PHI


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Write HIPAA Policies & ProceduresIncidental Uses and Disclosures

• Unintentional• Overhead phone

conversations when answered at the front desk.

• A patient passing by another room where treatment is taking place

• Everyday operations

Write HIPAA Policies & ProceduresAccidental Disclosures

• Faxing or emailing PHI to the wrong destination

• Disclosing PHI to an unauthorized person

• If harmful, must be disclosed to the patient.

• Always included on non-TPO disclosure log

Write HIPAA Policies & Procedures Faxes

PRIVILEGED AND CONFIDENTIAL: This document and the information contained herein are confidential and protected from disclosure pursuant to federal law. This message is intended only for the use of the Addressee(s) and may contain information that is PRIVILEGED AND CONFIDENTIAL. If you are not the intended recipient, you are hereby notified that the use, dissemination, or copying of the information is strictly prohibited. If you have received this communication in error, please erase all copies of the message and its attachments and notify the sender immediately.

Write HIPAA Policies & Procedures Emails

This email, including any attachments, may include PRIVILEGED AND CONFIDENTIAL information and may be used only by the person or entity to which it is addressed. If the reader of this email is not the intended recipient, or his or her authorized agent, the reader is hereby notified that any dissemination, distribution, or copying of this email is prohibited. If you have received this email in error, please notify the sender by replying to this message, and delete this email immediately.

Write HIPAA Policies & Procedures EOB’s and COB’s

• When coordinating benefits, blacken any other patient’s PHI on EOB

• Clear out anything that does not apply to the claim

• Otherwise is a violation of HIPAA law.


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Write HIPAA Policies & ProceduresMarketing

• Encouragement of purchase of product or service that is not for treatment purposes

• Part of a treatment plan is ok…such as information on asthma if that is the DX on file

• Face to face ok: Product of the month

Write HIPAA Policies & Procedures Use of Photographs

• Permitted but must be out of public view

• As part of a testimonial or other marketing effort, you must have authorization

• Can include in electronic or paper form

Write HIPAA Policies & Procedures What’s OK?

• Sign in sheets: minimal information—name, time, etc.

• Verification of Callers: PHI over phone--Password, SSN, DOB, Zip, Maiden Name

• Social Security Number: use sparingly, or last four digits only

Write HIPAA Policies & Procedures Phone Messages/ Appt. Reminders

• Reminders are good• Postcards are ok• Answering machines

are ok• Do not leave PHI on

the call, or results of test

• OK to say that you are reminding of an appointment and date/time

• Should include that information in the NPP

Write HIPAA Policies & ProceduresMore Common Sense

• Not required:– Private rooms– Soundproof rooms– Wireless encryption– Encrypted

telephones

• A good idea:– Have patients wait a few

steps back from counter– Curtains or screens– Speaking quietly– Files turned backward – Folders marked

confidential– All faxes/email that

contain PHI marked confidential

– Fax machines secure locations

Purpose of HIPAA Security

• Protect ePHIElectronic Protected Health Information

• Confidentiality• Integrity• Availability


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Step 2: Understanding the Rules:Types of Safeguards

• Administrative Safeguards

• Physical Safeguards • Technical Safeguards

Train Your Team Members• Ongoing training

required, updates• Access PHI on “need

to know” basis• Keep employment

records separate from treatment records

• Fully explain sanctions for failure to comply.

What Exactly is Policy

Policy: This is how we do things here, and why we do them.

An Example of PolicySample Policy: Physician Education Policy

PURPOSE:The purpose of physician and other practitioner education is to ensure

all providers understand and comply with federal and state laws, statutes and regulations applicable to the delivery of health care in a clinical environment.

POLICY:Physicians and other practitioners are required to attend all agreed

upon and scheduled educational programs designed for providers. Education will be conducted subsequent to medical record audit activity and with a frequency to meet the needs of the provider. Provider compliance education will be conducted at least annually.

Why You Should Have aStandard Operating Procedure

What is SOP?• SOP means Standard Operating

Procedure• This is the “way it is done”• How we implement the policy we have

decided upon• No corporation operates without this for

each position or job in the company• Why do we try to do without?


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Physical SOP Manual• Define where your

Physical SOP Manual is housed

• Decide who is responsible for each section of your SOP manual

• Define who will bring it to your team meetings

The KMCU SOP Flowchart

1. The person who performs the procedure writes out each steps as the steps are performed2. Follow your own instructions the next time you perform this activity to verify the accuracy


3. Have another team member perform your duties while following your written instructions4. Correct and clarify any areas of confusion, and re-test instructions, if needed


5. For ease of use, use lots of pictures, and illustrations and computer screenshots6. For accuracy with repetitive processes an actual checklist is preferred


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Team Meeting Accountability• A regular part of your

weekly team meeting should be a check-in on SOP Progress from each member of the team

• Everyone on the team is assigned a specific SOP to complete and a “by when.”

• Progress is reported weekly

Strategies for Better Defense

• Make a list of areas that are potential weaknesses and create policies/procedures

• Delegate and empower to share the work load among all members

• Train often and use a Training Log• Operate under the “team functions better

together” mentality. You’re all responsible for protecting the practice together!

Hold Regular Team Trainings• Training together as a

team helps build bonds

• Gain a shared understanding with unique strategies

• New ideas refresh energy in the practice

• Learn how to better serve patients


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The Numbers Add Up

• Typical Number of NP/Month: 20• Typical NP Case Average: $1800• Approximate Income: $36,000/month• Patients who drop out of care due to lack

of understanding of their problem or finances can = as much as 50%

• Approximate Income: $18,000/month• Lost income over a year: $216,000

Goals of a New Patient Phone Call

• Schedule the appointment• Schedule the appointment• Did I mention, Schedule the appointment?• Address financial issues if they bring them

up• Determine if they wish to use third party

assistance• Collect data for pre-verification if possible• Oh by the way: Schedule the

appointment!

• Have they seen another DC?

• Did they do things correctly?

• Do they understand what Medicare covers for Chiropractic?

• Are they “set” in their thinking?

Who Knows What They Have Been Told?

Important Concepts for Call

“Medicare expects you to cover the cost of the initial exam (and x-rays if that’s appropriate) that will be performed on the initial visit, in addition to your portion for covered chiropractic adjustments. You can expect this initial visit out of pocket to range from ______ to ________ depending on what services are performed. (The range should reflect your ChiroHealthUSA initial capped fee on the low end, and your actual estimated fees for a new patient visit on the high end.) When we see you here in the office, we’ll also tell you about ways for you to qualify for discounted fees in our office that can apply to this visit, for people just like you with Medicare that only covers part of your care in the office. Rest assured that we never turn anyone away from care due to their ability to pay, and we’re happy to work with you to make this fit into your budget so you can get the care you need.”

More Important Goals of NP Phone Call

• Develop rapport with the new patient. • Ensure they are in the right place and the

doctor has helped others like them. • Acknowledge that you are concerned

about them.• Remain positive and welcoming.• Determine whether they wish to use 3rd

party assistance so you can be more prepared.


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Goals at End of Day One • Patient understands that they’ve come to the

right place, and has developed rapport with the doctor.

• Doctor has gathered necessary clinical data to determine a DX and TX plan.

• Patient understands their financial responsibility for today’s visit and that details will happen after ROF visit

• Patient pays something toward their financial responsibility today

• Patient joins CHUSA if they wish to access discounted fee schedule, if appropriate

• Patient signs general office financial policy

Clinical Day One: Data and Rapport

• Gather data and educate

• Don’t try to do too much on visit one.

• Data collected will be analyzed to get the cause of the problem

• Touch and tell through the examination

H + E = D => TX

• History will drive the examination: ask good questions!

• Examination (including testing) with History will drive the diagnosis.

• The diagnosis will ultimately yield the treatment plan.

This is Your Goal! This is the most thorough exam I’ve ever had! I’ve come to the right place to get to the cause of my problem!

Financial Goals of Day One

• Patient pays something.

• Patient understands general financial policy.

• CHUSA is introduced for cash paying patients who wish to access a discounted fee schedule.

• Patient understands that finances are explained after ROF.

Beginning of Visit One

• Assess the Scenario• Begin on the right foot• Further the concept of

“This is how we do it here”

• Don’t be afraid to talk about finances in the right context


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Patient Friendly Medicare Education

• Patient Friendly Language

• Looks “Medicare Official”

• Starts the process on the right foot

www.patientmedia.com/medicare

A Simple Script: At the Return of Paperwork

“I’m going to review your paperwork now and prepare your file so we can get you in to see Dr. _____. This is a brochure that explains how Medicare works with Chiropractors. (hand brochure to patient) Please take a moment while I’m working with your paperwork to review it. During your consultation, Dr. ____ will be happy to answer any questions you have about it.” (Leave the patient to review the brochure while you prepare to take the patient back to the consultation room.)

During Visit One

• Doctor refers back to brochure at appropriate intervals

• Discuss Medicare and the expectations

• Through examination, help them understand function

End of Visit One

• This is where magic happens

• This is where we can help them understand most clearly

• The tone you set here will carry through the patient’s experience in your office

Definitions1. Dual Fee Schedules2. Improper Time of Service Discounts

Improper Collection Policies

3. Inducement Violations4. False Claims Act Violations5. Anti-kickback Statue Violations

107

1. Avoid Dual Fee Schedules

• Charging more to insurance companies than you do to cash patients– Considered illegal in

many states– Misrepresents charges

to carriers – False Claims Act

violation– May violate provider

agreements– Triggers investigations

» Florida» Geico

108


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2. Time of Service Discounts

• Discount based on bookkeeping savings– May or may not be

defined– Often not defensible or

unreasonable– May not be

permissible on Federally insured patients

109

3. Inducement Violations

110

• Per the OIG: “incentives that are only nominal in value are NOT prohibited by [inducement law]

• No more than $10 per item or $50 in the aggregate annually– Even one free

examination, x-ray, or therapy is a risk

Did Someone Say Groupon? 4. False Claims Act Violations

• Establishes liability when any person or entity improperly receives from or avoids payment to the Feds

• Prohibits “knowingly presenting or causing to be presented, a false claim for payment or approval

112

4. False Claims Act Violations

• Prohibits “knowingly presenting or causing to be presented, a false claim for payment or approval– Examples:

• Waiving deductibles or co-payments and not reporting to carriers

• Up-coding for higher reimbursements

• Down-coding based on payer type

113

5. Anti-Kickback Violations

A person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act. The statute defines “remuneration” to include, without limitation, waivers of copayments and deductible amounts (or parts thereof) and transfers of items or services for free or for other than fair market value.


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State Rules & Regulations•Time of Service Discount Percentages are permitted in some states.

•Not always defined!•OIG indicates 5-15% per 2009 opinion.

•PIP law (FL) prohibits charging more to PI patients than other patients.

NOTICE:STATE LAW DOES NOT SUPERCEDE

FEDERAL REGULATIONS AGAINST GIFTS &INDUCEMENTS AND CHARGING LESS

THAN FAIR MARKET VALUE!

115

You Are Likely Already Discounting

When a patient that has insurance enters your office for care –they are bringing another “person” to the relationship

Doctor-Insurance Company

Insurance Company - Patient

Patient-Doctor

80% Insurance Company20% Patient

Initial VisitExam: $120X-Rays: $130CMT: $6597014: $35

Total: $350

Routine VisitCMT $65

97110: $5097014: $3597012: $35

Total: $185


Total: $220


97110: $3097014: $1597012: $15

Total: $95

98940: $25.1598941: $34.8698942: $42.75

100% Poverty: 75% Discount125% Poverty: 50% Discount150% Poverty: 25% Discount


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Doctor-ChiroHealthUSA

Patient-Doctor

ChiroHealthUSA- Patient

0% ChiroHealth USA100% Patient

Patient-Doctor


Total: $350


97110: $5097014: $3597012: $35

Total: $185

Initial VisitCapped Fee: $150Or 20% Discount

Routine VisitCapped Fee: $65Or 20% Discount

Modalities: $10Procedures: $20

100% Poverty: 75% Discount125% Poverty: 50% Discount150% Poverty: 25% Discount

Re-Exams: $25Each Film: $15


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What About Professional Courtesy?

• Review the Fact Sheet

• Who do you offer courtesy to?

• Staff?• Other DCs?• What about when

insurance is involved?• Write your policy

Goals for Day 1.5

• Doctor has completed diagnosis and treatment plan

• CA has received all pertinent info so the patient’s responsibility can be determined

• The calculator you choose to assist you can be prepared in advance and ready for the FROF

Clinical Day 1.5

• Doctors must get their “work” done before the next visit.

• Treatment plan and DX is necessary for Financial ROF.

• Whatever handouts happen at ROF need to be prepared.

Goals of Insurance Verification• Gather detail regarding coverage to assist

with FROF• Find out what codes are covered and what

is the patient’s responsibility• Confirm eligibility of the patient and their

method of coverage • Glean from Verification Bible information

for benefits where possible• Create templates for efficiency

To Begin With….

• One verification form will not work for every type of insurance

• Medicare, Personal Injury, Medicare Advantage, Medicare Secondary, Worker’s Compensation

Major Medical Verification

• Typical verification questions

• Verification of eligibility

• Checking for medical review policy

• Checking for summary plan documents-ERISA

• Setting up templates for most typical insurance plans


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#1: Does Specific Medical Review Policy Exist?

#2: Use Diagnosis Codes That Meet Requirements

Financial Day 1.5

• Team members must have insurance verified.

• Verification + TX Plan = FROF

• Payment plan calculations should be in place, ready for FROF.

• Morning huddles ensure all is ready for ROF/FROF

Payment Plans• Set up legal and

correct payment plans.• Once you bill/charge

correctly, you can collect according to your plan.

• Set up monthly payment plans along the way so YOU control collections.

• Check with your managed care contracts for restrictions.

Clinical ROF

• Doctor gets agreement on “4 yeses”

• Last “yes” is agreement to pay for care

• Transition by passing baton to team member performing FROF

• Make the private conversation public

• Exit so team member can begin FROF

Financial Report of Findings

• Review the benefits or lack thereof

• Review the plan they just got from the doctor

• Estimate to the best of your ability

• Explain your processes

• Visit by Visit vs. payment plan


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4 Yeses…4 Agreements

• Yes doctor, I understand I have a problem and want to get it fixed.

• Yes doctor, I understand that healing takes time and I will keep all of my appointments.

• Yes doctor, I want to fully participate in getting well and I will attend at least one Healthy Lifestyles Workshop

• Yes, I’m aware I’m financially responsible and will pay “X” dollars over “Y” period of time.

Payment Plans• Set up legal and

correct payment plans.• Once you bill/charge

correctly, you can collect according to your plan.

• Set up monthly payment plans along the way so YOU control collections.

• Check with your managed care contracts for restrictions.

Offer Affordable Options

• Get your “Fourth YES” with ease

• Make care affordable for everyone

• Get your patients the help they need, when they need it

• Third Party care/credit cards can make the difference

The Three Most Important Considerations

• You must CHARGE correctly…use the correct fee schedule

• You must BILL it correctly…use the right fee whether billing patient OR carrier

• You can COLLECT according to your policies

What Makes a Payment Plan Compliant?

• Use of proper fees to calculate patient responsibility

• Appropriate estimate of medically necessary care to be paid by 3rd

party• Automated payments

from credit card handled properly

• No discounts given on 3rd party reimbursable portion of care

Medicare Payment Plans

• Once you have charged and billed correctly, you may collect according to your written policy

• OK to allow them to pay their portion on a monthly payment plan

• OK to incentivize excluded services 5-15% if prepaid…but we discourage this


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Payment Plans = Opportunities

• Patients on payment plans: – stay under care

longer– tend to get all the

care they need, including rehab and other items

– are more likely to have family under care

Financial Report of Findings

• Mr. Pitt, after verifying your insurance, we discovered that you do have some insurance support for your financial responsibilities, and that is great news! Your insurance carrier will shoulder the majority of the cost of your care.

• For additional financial assistance with your prescription of care, I am recommending membership with ChiroHealthUSA(CHUSA). You will be able to access discounted fees on all services that may not have other coverage and it will be a huge savings for the $39 annual investment for full family coverage.

• As you can see, your total estimated responsibility is only $960 (9-60). This $960 (9-60) includes all of the services Dr. Brown has recommended for you, including your pillow and other items necessary to complete your treatment. In our office, we offer three options for taking care of your balance.

Option One: Pre-Payment

• Mr. Pitt, option one is our most popular option. Dr. Brown would like to pass along some savings to you for allowing us to forego the bookkeeping responsibilities of collecting throughout the course of your treatment.

• She has decided that if you are able and willing to take care of this estimated balance today, we will pass along a 10% discount on your non-insurance services. In this case, your savings would be an additional 81 dollars. How does this sound?

Option Two: Monthly Budgeted Payments

• Mr. Pitt, sometimes our patients need to spread their payments out a little further. Because of this, we are willing to in-house finance your balance across several months to make it easier to fit into your budget.

• As you can see, we have calculated this at 6 months and with a down payment of $160 (1-60) today you could stretch this over 5 additional monthly payments of $160 (1-60). This will allow you the opportunity to spread this across several months, without any interest, and it is easier for us to process your payment only once a month. We will keep a credit card on file, and with your authorization, process your payment once a month. Is this option best for you?

Option Three: External Care Card • Mr. Pitt, we have partnered with a great health

care financing company called The HELPCard. What we love about The HELPCard is that we can help you get your monthly payment to an amount small enough that will meet your monthly budget’s needs and it will act just like a credit card.

• The best news is, if you pay it off within an appointed amount of time, that can be as long as 12 to 18 months, there is no interest. This is like using someone else's money free of charge. As you can see here, we have calculated that your payment would be $80 (80) if we stretched your monthly obligation out as far as 12 months. Would that work better?

Objection: Wants to wait till next visit

• It's not a problem Mrs. Jones, if you need to speak to your husband. I know that I wouldn't want to make a decision like this without my husband present, either. That is why we hoped he would be able to attend this visit so that he could better understand what's going on with your care.

• Let's go ahead and take care of your balance to date, so we can start with a clean slate on the next visit. After you've had a chance to visit with Mr. Jones we’ll be able to recalculate a payment plan that will work well in your budget. Today's charges added to yesterday's balance will be $150 (1-50).


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Objection: Wants insurance only

• (CA) I understand Mr. Smith. I am not authorized to change your prescription of care; let me get Dr. Jones since that is different from what he said.

• (DC) Mr. Smith, I understand what you may be thinking. However, receiving only the care covered by your insurance would be a tremendous disservice to you. Your third-party coverage was never meant to cover all of your care. That's the reason that we became a provider for ChiroHealthUSA(CHUSA) to be able to extend a contracted discounted to you for the portion of your care that is an out of pocket expense.

• I would much rather look at how we can spread this across more time and work with your monthly payment, than have you consider not following all of my recommendations. The portion of care covered by your insurance will only be acute-focused care. To stop your care at that point would be like taking your braces off after just a couple of months of treatment. Again, that's the reason why we work to make this affordable.

Objection: Too far out of my budget

• Yes, Mary, I understand that this amount may be outside your budget. The truth is that it sounds like you have two problems. You have a health problem and a financial problem. We know you’re in the right place for your health problem. In order to help you with the financial problem, help me understand what you think you can afford.

Pros of Treatment Plan Automation

• Scheduling out to first re-examination ensures it gets done. Doctors must assist here!

• Nothing slips through the cracks.

• Even if patient won’t commit, placeholders are used.

• Find a section of the schedule for reminders.

Pros of Payment Plan Automation

• Automation makes it easier for front desk• Automation helps patients keep their

commitments of appointments and care plans• Payments become budget sized• Payments of the patient portion could open

the door to payments from 3rd party otherwise not available

• The cycle of care may change: no need to change payment plan

• At the end of treatment, it all evens up

Payment Card Industry (PCI)Data Security Standards

• Mandatory compliance program resulting from a collaboration between credit card associations to create common industry security requirements for cardholder data.

Who Has to Worry about PCI?

• If you transact credit card business, you have to worry about it.

• Merchants (that’s you doctor) and 3rd party providers (CashPractice™) who process, transmit, or store cardholder data are required to adhere to certain data security standards.


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Consequences of Non-Compliance

• Forensic Investigation• Steep monetary fines

($25k per incident) levied by the card industries

• Lawsuits• Damage to reputation• Bad publicity• Revocation of credit

card business privileges.

PCI-DSS ExpectationsBuild and Maintain a Secure Network

1. Install and maintain a firewall configuration to protect data

2. Do not use vendor-supplied defaults for system passwords and other security parameters

Protect Cardholder Data

3. Protect stored cardholder data 4. Encrypt transmission of cardholder data and

sensitive information across open public networks

Maintain a Vulnerability Management Program

5. Use and regularly update anti-virus software 6. Develop and maintain secure systems and

applications

PCI-DSS ExpectationsImplement Strong Access Control Measures

7. Restrict access to data by business need-to-know 8. Assign a unique ID to each person with computer

access 9. Restrict physical access to cardholder data

Regularly Monitor and Test Networks

10. Track and monitor all access to network resources and cardholder data

11. Regularly test security systems and processes

Maintain an Information Security Policy

12. Maintain a policy that addresses information security

Healthy Lifestyle Workshop (HLW)

• The Healthy Lifestyle Workshop is the continuation of the ROF/FROF process.

• It gives you the opportunity to share the chiropractic story, get family support for your new patient/new practice member

• Your relationship is strengthened when a patient understands the importance of their Nervous System …to their health, well-being and day to day functioning.

100% Attendance• Guarantee 100% attendance at your

Healthy Lifestyles Workshops by using the psychology and the power of persuasion

• Explain that all NP are required to attend• Explain it will save them time and money• Get a written agreement – they write it• 1 day prior - call the patient and their guest


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What’s In It For Me?

• “I find that my patients who attend at least one Healthy Lifestyles Workshop get better faster, stay well longer, and care tends to cost less money”

The Financial Touch Base

• When we initially speak to the patient in the Financial ROF, we must remember they are in pain.

• When a patient is in pain, their ability to remember is impaired.

The Financial Touch Base

• Typically between visit 4 – visit 10 the patient has less pain, and can better concentrate on the financial details you will review.

• Your team has also had time to build rapport and trust.

Components of the Financial Touch Base (FTB)

• Introduce yourself, including your title.

• This helps set the tone as a formal meeting.

• Remember, the patient may not remember your name.

• Great opportunity to incorporate team member business cards.

Components of the Financial Touch Base

• Tell the patient how often you will submit claims to their insurance company.

• Show them a CMS-1500 insurance billing form so they become familiar with it.


• Explain that it is possible that an insurance check could be sent to their home address in error.

• When accepting assignment, make sure that the patient knows to immediately bring any insurance checks into you specifically.

• That way you can apply the payment to their account.


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• Show the patient several HIPAA scrubbed examples of Explanation of Benefits (EOB) from the various insurance companies.

• Tell them they may receive EOBs at home and that they should bring them into the office so you will have a copy for their file.

• “Sally, sometimes the insurance company sends you information, and they forget to send us a copy. Please bring in any correspondence for my review.”


• Engaging the patient in the Financial Touch Base allows the Financial Counselor to build rapport.

• Once rapport is built, asking for referrals becomes effortless.

Graduation to Maintenance Care• Medicare patients will

likely move in and out of active treatment while a patient in your office.

• Have a clear understanding of the definition of maintenance care and follow the rules

MaintenanceCMS defines Maintenance Therapy as: "Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy."

Episodes of Care Maintenance• Wellness

– Prevent disease– Promote health– Prolong/enhance the quality

of life• Supportive

– Maintain or prevent deterioration of a chronic condition


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Three Choices for Fees in Maintenance Care

• Charge Medicare allowable fee or limiting fee

• Charge your actual fee• Charge a discounted

fee for maintenance if the patient qualifies and you offer this to ALL types of patients

• Codify this in your compliance policy

Option One: Medicare Allowable/Limiting Fee

• Continue to charge the allowable or limiting fee in maintenance care

• Charge that fee when billing for active treatment

• Set policy that says THIS is your fee for all phases of care: acute, chronic, or maintenance

Should I Consider This Option?

Pros• Super simple for the front

desk and the patient• Much easier to explain

when maintenance care begins

• Doesn’t feel confusing to the patient since the fee is the same all the time

Cons• The doctor won’t be able

to collect actual fee, even for maintenance care CMT

Sample Policy: Option OneIt is the policy of this office to charge the published, regulated fee schedule for the spinal Chiropractic Manipulative Treatment (CMT) codes delivered to Medicare patients, whether the treatment is for acute, chronic, or maintenance care. All other treatment rendered in the office is considered to be statutorily non-covered under Medicare. Therefore, this office charges our full and actual published fee schedule for these services. If the patient qualifies for discounts under our available Hardship Policy or a Discount Medical Plan Organization (DMPO) we may participate in, that fee schedule will be extended to the patient. In addition, this office will charge and attempt to collect any and all deductible and co-insurance due from the patient.

This office’s providers are (participating/non-participating) with Medicare. We locate the published, regulated fee schedule applicable to our office on our Medicare carrier’s website on an annual basis, and update our fees accordingly. (Choose one): As a participating provider, we bill the Medicare Participating Allowable fee for each of the three spinal CMT codes during active treatment. OR As a non-participating provider, we bill the Medicare Limiting fee for each of the three spinal CMT codes during active treatment.

If a Medicare patient elects to receive Chiropractic Manipulative Treatment services that the provider deems are likely to be denied by Medicare, this patient will indicate their choice on the appropriate Medicare Advance Beneficiary Notice (ABN) form, and will be informed of the fee for the service prior to treatment. This office will continue to charge the (allowable/limiting) fee during any maintenance care and will collect this fee from the patient. The patient will direct the office whether to submit this maintenance care to Medicare by their choice on the ABN form.

Option Two: Charge Actual Fee for Maintenance Care

Medicare Claims Processing Manual: Chapter 30; Section 50.7.3A

Collect Actual Fee for Maintenance CMT

• As the manual states, it’s OK to begin charging ACTUAL fee during maintenance with ABN signed

• Requires carefully worded FROF and discharge discussion of fees

• We recommend Par providers BILL actual fee

• Non-Par Providers must bill Limiting Fee


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Sample Policy: Option TwoThis office’s providers are (participating/non-participating) with Medicare. We locate the published, regulated fee schedule applicable to our office on our Medicare carrier’s website on an annual basis, and update our allowable fees accordingly. (Choose one): As a participating provider, we bill our published, actual fee for each of the three spinal CMT codes during active treatment submitted to Medicare. When payment is allowed by Medicare, we take the appropriate contractual write offs as directed on the Explanation of Medicare Benefits, charging the Medicare patient ONLY the applicable co-insurance or applied deductible fees. OR As a non-participating provider, we bill the Medicare Limiting fee for each of the three spinal CMT codes during active treatment.

If a Medicare patient elects to receive Chiropractic Manipulative Treatment services that the provider deems are likely to be denied by Medicare, this patient will indicate their choice on the appropriate Medicare Advance Beneficiary Notice (ABN) form, and will be informed of the fee for the service prior to treatment. This office will charge our ACTUAL fee for the appropriate CMT code during any maintenance care and will collect this fee directly from the patient. The patient will direct the office whether to submit this maintenance care to Medicare by their choice on the ABN form.

All other treatment rendered in the office is considered to be statutorily non-covered under Medicare. Therefore, this office charges our full and actual published fee schedule for these services. If the patient qualifies for discounts under our available Hardship Policy or a Discount Medical Plan Organization (DMPO) we may participate in, that fee schedule will be extended to the patient. In addition, this office will charge and attempt to collect any and all deductible and co-insurance due from the patient.

Should I Consider This Option?Pros

• The doctor can collect actual fee, rather than this limited fee schedule for maintenance care.

Cons• Patients may have difficulty

understanding the increase• They may already have

confusion around the maintenance concept, and could have pushback around increased fee

• Confusion can lead to calling Medicare raising a flag

• Par providers may go from as small a copayment as $5 all the way to $50

Option Three: Publish A Maintenance Fee Schedule Anyone

Can Access• The safest, and cleanest way to do this is to join a DMPO like ChiroHealthUSA

• Within that fee schedule, post a fee for maintenance CMT, regardless of levels

• Anyone who is a member can access that fee schedule

Sample Policy: Option ThreeThis office’s providers are (participating/non-participating) with Medicare. We locate the published, regulated fee schedule applicable to our office on our Medicare carrier’s website on an annual basis, and update our allowable fees accordingly. (Choose one): As a participating provider, we bill our published, actual fee for each of the three spinal CMT codes during active treatment submitted to Medicare. When payment is allowed by Medicare, we take the appropriate contractual write offs as directed on the Explanation of Medicare Benefits, charging the Medicare patient ONLY the applicable co-insurance or applied deductible fees. OR As a non-participating provider, we bill the Medicare Limiting fee for each of the three spinal CMT codes during active treatment. All other treatment rendered in the office is considered to be statutorily non-covered under Medicare. Therefore, this office charges our full and actual published fee schedule for these services. If the patient qualifies for discounts under our available Hardship Policy or a Discount Medical Plan Organization (DMPO) we may participate in, that fee schedule will be extended to the patient. In addition, this office will charge and attempt to collect any and all deductible and co-insurance due from the patient. If a Medicare patient elects to receive Chiropractic Manipulative Treatment services that the provider deems are likely to be denied by Medicare, this patient will indicate their choice on the appropriate Medicare Advance Beneficiary Notice (ABN) form, and will be informed of the fee for the service prior to treatment. This office has a published “maintenance” fee schedule that is offered to any patient receiving maintenance or wellness based care that is not covered by their applicable third party payer, including Medicare. Medicare beneficiaries wishing to continue in Maintenance care will be made aware of this maintenance fee in conjunction with our network-based, ChiroHealthUSA fee schedule. They will be charged this maintenance fee during any maintenance care and we will collect this fee from the patient. The patient will direct the office whether to submit this maintenance care to Medicare by their choice on the ABN form. If it’s billed to Medicare, the fee will be represented as the amount of the maintenance fee actually charged, and not any other fee.

Should I Consider This Option?Pros

• Patient has likely already joined DMPO for excluded services—easy transition

• Much easier to explain when maintenance care begins

• Doesn’t feel confusing to the patient since the fee is for “maintenance”

Cons• Lots of confusion in this

area about whether one can assign a maintenance fee outside of a DMPO

• Requires LOTS of explanation to the patient about who decides what is maintenance

• Maintenance adjustments cost the same as active treatment to the practice

The Three Most Important Considerations

• You must CHARGE correctly…use the correct fee schedule

• You must BILL it correctly…use the right fee whether billing patient OR carrier

• You can COLLECT according to your policies


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ICD-10: The Essentials

Why in the World Do We Have to Change?

• WHO says so!• US is the only civilized

country NOT on ICD-10• Too much complaining

about costs and time

ICD-9 to ICD-10 Awareness

• What are the codes?

• How are they different?

• What does all of this mean?

• How do we make the transition?

What’s Wrong with ICD-9?

• ICD-9 is 30 years old• ICD-9 lacks specificity • ICD-9 does not reflect

new services • ICD-9 doe not

compare costs and outcomes

• ICD-9 is limited (13,000 codes)

What Can I Expect with ICD-10?• ICD-10 will encompass

more precise documentation

• ICD-10 will allow for more accuracy when determining medical necessity for the services rendered

• ICD-10 will allow providers to code more accurately which will contribute to the health care quality improvement initiatives

ICD-10 Organization• Address and

prioritize tasks– Date software

vendors will be compatible

– Upgrade schedules– Readiness and

testing schedules – Training schedules

for• Physicians• Office Staff


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Managed Care Contracts• Identify all your payers• Review the policies

related to ICD-9• Reimbursements tied to

diagnosis• Modify agreements• Determine their

timelines for testing

Managed Care Contracts• Payer policy changes

= Payment impact– Review new payment

policies– Improve coding and

documentation– Communicate

changes to staff– Dual coding– Know important dates

Can We Just Crosswalk from ICD-9?

• General Equivalence Mappings (GEMs)

• Some pointing based on the initial set up

• Three possible ways to define subluxation: M99.01, M99.11, or S13.11

• Time will tell

ICD-10 Coding and Documentation• Site

• Laterality – 5th or 6th digit - Sciatica– Left – M54.31– Right – M54.32

• Episodes of care– 7th digit– A D S

• Injuries

Some Examples

• Chapter 13-Diseases of the Musculoskeletal System and Soft Tissue

• Our Wheelhouse• M-00 through M-99

series

Examples of Common Codes• Cervicobrachial

Syndrome– M53.1– (excludes 2: cervical

disc disorder)• Cervicocranial

Syndrome– M53.0– Posterior cervical

sympathetic syndrome

• Coccygodynia– M53.3– Defined as

Sacrococcygeal disorders, not elsewhere classified

– In the neighborhood with Spinal Instabilities

• M53.2X2-Spinal instabilities, cervical region


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So What is “Excludes 1” or “Excludes 2”?

• Similar to Correct Coding Initiative Edits for CPT Codes

• Dictates when certain codes can be used together and when not

• The explanation will be helpful in the long run

Talk About Detail!• Take 847.0 Cervical

Sprain– Could be S13.4xxA– Could be S13.8xxA

• Much more detail is possible in ICD-10

• Item one: sprain of ligaments of the cervical spine

• Item two: sprain of joints and ligaments of other parts of the neck

Some Examples External Cause Codes

• The most general chapter

• Symptoms that are more specific are included in the other chapters

• Diagnosis will always be sequenced before the symptom

For Example• S30.0xxD-Contusion

of lower back and pelvis, subsequent encounter

• We will have to wait to see whether this will be required throughout the episode of care, or only on first visit using “A”

V, W, X, Y Codes

For Fun• Bus Occupant V79.9

(collision with) Animal in traffic being ridden

• Bus Occupant V70.3(collision with) animal, non-traffic

• Bus Occupant V70.4(collision with) animal, while boarding or alighting


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Case Example

• While playing tennis in a tournament at the Clay Court Country Club, a male player sprained his right wrist and was treated by his Chiropractor close to the courts.– S63.5001A Unspecified sprain of right wrist,

initial encounter– Y93.73 Activity, racquet and hand sports– Y92.312 Tennis Court (place of occurrence

for external cause)

What Should I Do Now?

• Concentrate on perfecting documentation

• Learn the subtle nuances in your current diagnosis protocols

• Begin to discern what each means to you

Mark the Calendar Now!

• CMS has given carriers until April 1 to publish LCDs with ICD-10 codes

• ACA, COCSA, State Associations, KMCU, Chiro-Code, will be disseminating information

• That gives you 6 solid months to prepare!

Know the IT Impact You’ll Face• What changes will need

to be made?• Do they have available

upgrades?• When will the upgrades

be available?• Upgrade and your

maintenance agreement

• Will they continue to provide support?

• Parallel coding?• How long will my

system be down?

IT Impact• Storage capability• Expanded number of codes• Field size changes

• 3 – 5 characters• 3 – 7 characters

Cross Walk Exercise

• Make a list of the 10 most common DX codes you tend to use

• Can you list 10 more?• Run the list from your

computer• Practicum Exercise!


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Resources

• Transition Tools– http://www.icd9data.com/– www.cms.gov– http://aapc.com/– http://www.ahima.org/icd10/– http://www.cms.gov/Medicare/Coding/ICD10/downloa

ds/ICD10SmallandMediumPractices508.pdf– http://www.cdc.gov/nchs/data/icd/icd10cm_guidelines

_2014.pdf

Questions? [email protected]

Documents

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