Archive for June, 2009

Co-Pays, Coupons & Discounts: When Free Isn’t

by Tom Necela on June 30th, 2009 in Billing, Business, Collections, Medicare

Reading time: 12 – 20 minutes

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After virtually every seminar I conduct, a DC asks me a question privately about discounted services. Whether it’s free exams, low-cost x-rays, or waiving co-pays, the doc is usually concerned that he is violating some rule or law by marketing his practice in this manner and too embarrassed to ask the question publicly.

Often, the DC’s will confide that they don’t like giving away services but that some practice management “guru,” new patient “master” or marketing “expert” recommended this as a viable way of obtaining new patients.

I know I have been taught that “if you can’t say anything nice don’t say anything at all.” But if I actually was able to adhere to that, there is little chance of you ever reading one of my blogs, columns or books as I suspect that biting one’s tongue doesn’t translate well on paper or online.

So, while I am not about to debate the effectiveness that these promotional methods may have or wax on about their effect on the public image of chiropractic, I will say a few words about their legitimacy in the realm of billing and compliance. (Excuse the generalizations here as I cannot devote enough space to address each state’s individual laws separately)

  • Most providers are required to bill for all services rendered per our insurance contract. Therefore, the routine use of free exams as a method of getting new patients are likely a violation of that contract.
  • Most insurance contracts prohibit providers from  waiving co-payments or co-insurance amounts. Some state laws also have specific provisions that waiving a co-payment is illegal.

  • Providing deeply discounted services may also be problematic, particularly for Medicare. For example, if your normal exam fee is $100 and you run a promotion that gives the exam away for $29, you be faced with penalties from Medicare for “inducement.” Per Medicare regulations, you are not allowed to give away anything over $10, else you may be accused of illegally enticing a patient to use your office or your services.

With the advent of Medicare RAC contractors coming our way, increased scrutiny from third-party payers and post-payment audits becoming all too common, this may be a good time to review your standard operating procedures within your clinic.

Frankly, just because you’ve been doing some promotion for a while, doesn’t guarantee its legitimacy or legality.  Sorry if I am the first to tell you, but the days are gone when you could actually tell if you are doing something correctly by the fact that you are paid for it.  Welcome to the new era:  you can perform the service, bill it, get paid — and THEN – someone can ask for their money back or fine you for doing so!

If you think that I am inflating the seriousness of this problem, think again. I make a habit of reviewing my consulting client’s websites and also have viewed enough chiropractic websites to virtually guarantee my optometrist a lifetime residual income.

What surprises me is how many clinics advertise discounts or freebies that are in direct violation with Medicare and/or their state laws.  By my very non-scientific estimation, I would say that half of the chiropractic websites out there are offenders. Four words if you are in this category: take it down now!  You’d be better off with no web presence than one that gets you in hot water.

Again, I am not saying such promotions are not effective. However, violations of statutes can bring up to $10,000 per incident fines. Certainly, that reduces the overall profitability of obtaining that patient into your clinic and gives you more potential headaches.

There are many legitimate ways to boost your revenues. In my consulting business, I focus on proper billing, coding, documentation and collections. We also look at your practice to see if it is ripe for expansion in other areas that could prove profitable. However, one thing that I constantly advise my clients is to make sure that what they are doing is above board.

So, before you get involved in some marketing scheme that could land you in trouble, consider the potential consequences. Before you give in to a patient’s request to waive a co-pay, weigh the costs. And before you give just about anything away to a Medicare patient, consider the fact that the patient will likely be dead and gone before you ever finish paying fines you incurred on their behalf. A little morbid, I know, but sometimes reality is just not pretty.

I may be simplifying things a bit,t but in my opinion, I would much rather keep all of what I make (minus whatever inevitable taxes they will extract from me), than make more and risk getting it taken away.

You might be thinking, well how am I going to afford all my fancy clothes, my exotic vacations and shiny sports car?  As I said before, there are many legitimate ways to increase your income, so don’t get your feathers ruffled just yet.  Plus, my guess is that your oldest pair of jeans will look good in comparison to those orange suits they hand out in prison!

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Securing Our Chiropractic Future

by Tom Necela on June 26th, 2009 in Business, Medicare, Politics

Reading time: 2 – 3 minutes

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Let me challenge you today on a vital issue in regards to the future of chiropractic.

Be forewarned – unlike my usual writings,  you will find no specific advice on proper coding or documentation. There are no billing “secrets” shared within the paragraphs below. Nothing will be found that will help you discover find errors you are making in the area of collections. In fact, not a shred of practice management advice will be given.

Despite the curious lack of advice on my part, today’s column may have the potentially BIGGEST IMPACT on your practice – if you act quickly – than any or all of the items above.

Unless your head has been firmly planted in the sand, you are undoubtedly aware of the mysterious frenzy over health care reform that has invaded Capitol Hill.  While specifics are a bit lacking right now, one thing is certain:  as chiropractors, we must seize the opportunity that has been placed before us to secure our future.

In the wake of upcoming changes, we all now have the ideal moment to voice our opinions to President Obama and our representative politicians.

Do not delay! Do not miss your chance! Most of all, do not stand by while our chiropractic future slips out of our hands.

A simple letter will do, but there is so much more that can be done for those who wish to get involved.

To give credit where it is due, this column was inspired by Dr. Gerry Clum, President of Life Chiropractic College West who has implemented a simple, straightforward, strategic plan to secure our chiropractic future.

Here’s my challenge and your three-step “To-Do List”

  1. View Dr. Clum’s plan for securing our future on the LifeWest website .
  2. Write your letter to President Obama and your state legislators
  3. Persuade ALL your DC friends to get involved by directing them here and/or to the LifeWest website for more info

That’s it — three easy steps to secure your future, your patients’ future and the future of the chiropractic profession.

Until next time,

Tom

(A special thanks to Dr. Clum for permission to post his plan on this blog)

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“Meaningful Use” of EHR for Defined- Finally!

by Tom Necela on June 23rd, 2009 in Billing, Documentation, EHR / EMR, Uncategorized

Reading time: 3 – 4 minutes

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For all of you who have been doing your homework in regards to purchasing an EHR program, we have some concrete news — finally! Until now, the path to see if you can qualify for President Obama’s stimulus incentives has been pretty murky and no one was exactly clear on the definition of “meaningful use” of EHR technology that qualifies you to receive federal funding.

While many EHR companies have stepped up their advertising trying to entice you to get on board with their company pronto, the reality of the situation is that they did not know if their product actually would meet the criteria to get you some of Uncle Sam’s money. This was mainly due to the fact that no one knew the criteria!  Unfortunately that didn’t stop many EHR companies from attempting to lure you towards their product, but that’s another story for another day.

The BIG NEWS is this:  The Office of the National Coordinator for Health Information Technology (ONC) has finally released its preliminary definition of “meaningful use” June 16, 2009.

Here it is in a nutshell.

Beginning in 2011, Medicare physicians who implement and report meaningful use of electronic health records will be eligible for an initial incentive payment of up to $18,000, and early adopters could receive a five-year bonus of up to $44,000.

The definition for achieving meaningful use of health data includes three parts:

  1. Data capture and sharing by 2011.
  2. Advanced clinical processes by 2013.
  3. Improved outcomes by 2015.

You can also go to the ONC website to read the definition in its full glory.

But…

Before you get too excited or we spend hours discussing the ramifications of “meaningful use” in the chiropractic setting, there’s a chance for bad news as well.

Oh come on, you didn’t expect that?  This is the government we’re dealing with!

Here’s the bad news: there is still a chance to submit opinions on the preliminary definition for meaningful use until 6/26/09 so… the definition may change.

Although the definition may be still a bit in the dark, one thing will probably emerge clear:  we will see a new wave of advertisements from EHR companies pretty soon. And don’t be surprised if the ads feature buzzwords like “data capture,”  “advanced clinical processes” and “improved outcomes” in them.  While that may propel some of your colleagues to feel a sense of urgency to purchase a system to capture stimulus dollars – YOU my friends, will know the difference: no one truly knows if their system will qualify for federal $$$.

So, if you’re purchasing an EHR because it’s the best thing to do for your practice (and it very well may be!), go right ahead.  Just don’t buy one because some salesman is telling you that you will definitely get a nice fat check back from the feds.  The salesman will certainly get a check based on your purchase; you, on the other hand…well…let’s wait and see.

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Chiropractic Cash Flow Crisis: What to Do Now!

by Tom Necela on June 16th, 2009 in Billing, Business, Coding, Collections, Documentation

Reading time: 12 – 20 minutes

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Recently, Business Week reported on the growing number of cash-crunched entrepreneurs who are suddenly finding out that their credit limits have been either suspended or downsized. It’s an ugly issue that all chiropractors hope to avoid, but the reality is that healthcare is not totally immune to the tightening of economic belts around us.

In fact, according to the American Hospital Association, 50% of America’s hospitals are currently operating in the red, up 17% from 2007. In the stats from the Small Business Watch report add up correctly, chiropractors are no exception. The May 2009 edition of the report indicated that 50% of small business owners have experienced temporary cash flow problems in the last 90 days.

Because many practices see a significant portion of their income from third party reimbursements, insurance companies (who are feeling the bite of the economy as well) that delay, deny or routinely underpay our claims can have a major impact on our cash flow. As the number of people who can afford insurance decreases, as members pay their insurance premiums late and create cash flow problems for the insurance companies themselves, be assured that it will get proportionally more difficult to get reimbursed from third party payers.

As chiropractors, what can we do to either proactively plan to avoid these struggles or remedy them as quickly as possible. Rather than gripe about the injustice of the system where banks and insurance companies can change policies at their own whim, here’s a list of action steps to take NOW toward some workable solutions:

  • Consider Medical Factoring. This is a little used route in chiropractic, but common in medical practices. Essentially, you receive a line of credit for your Accounts Receivables. The Medical Factoring company will loan you money based on the presumption that you will eventually be paid for the work that you do. If you are having serious cash flow issues, consider this option before taking major budget cuts, firing staff or eliminating necessary expenditures. See International Factoring Assn for more info
  • Eliminate Waste. Hopefully, your front desk CA’s salary is not a target, but you should look carefully within your practice to determine if there is unnecessary spending going on. This would be a good time to evaluate ongoing bills by comparison shopping to see if you can save some money. Take nothing for granted. Make a list of all routine expenditures (phone bill, internet, x-ray processing, ancillary products, etc) and have the most budget conscious C.A. spend a few hours bargain shopping. Here’s a recent success story: One of my clients suffered a health issue that put him out of work for nearly six months. He acted on my suggestion to evaluate every expense in order to keep his office afloat on a bare bones budget in his absence. He reported that his very thorough C.A. found nearly $2800 worth of bloated expenses to put on a diet to the tune of a $33,000 per year savings! The doctor’s cost? 6 hrs staff time @ $10/hr!

  • Bullet-Proof Billing, Coding & Documentation. You cannot afford the luxury of delayed or denied claims due to internal errors in the billing, coding or documentation department. Even if your clinic is producing vigorously, do you really want to waste dollars on preventable errors? If your practice management or billing software has a “denial report,” run it. See all those claims listed? That is work you have already done for which you have not been paid; worse, it may be your fault. At a recent seminar I was giving at a chiropractic college, I asked new grads how much training they received in Billing, Coding, Documentation or Collections. If you are a doc who has been in practice for a decade or more and feel slighted by the lack of “practical” skills you were taught in this department, you are not alone. While it may be appalling to some, the new DC’s received the same amount of training in these skills as you: zero.

Perhaps it’s time you dedicated some resources to the backbone of what get’s you paid each and every day. Have your staff and/or your software check to make sure your claims are clean BEFORE they leave your office. Attend a seminar on billing, coding or documentation strategies (I’ve got two coming up in Seattle and Portland with Jim Bowen). Fed up with trying to piece all the info together? Don’t know where to start? Help is available: my email is Tom@strategicdc.com.

Hopefully, everyone reading this is informed enough that these are mere warnings or proactive tools you can use in an emergency. If so, congratulations and keep up the good work. If these words hit a little too close to home for your comfort, get started on fixing these problems so you can turn things around as quickly as possible!

Tom Necela, DC, CPC

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ACA Responds to New Medicare OIG Report

by Tom Necela on June 4th, 2009 in Documentation, Medicare, OIG Report

Reading time: 3 – 4 minutes

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For those of you who have heard the news about the newly updated 2009 Medicare OIG Report, you probably heard that chiropractors still did not fare very well.  The now infamous 2005 OIG Report blasted chiropractors for a significantly high claims error rate and, unfortunately, the 2009 OIG Report is not very flattering either.

However, as the full text of the report emerged and details were examined, many in the chiropractic profession were quick to note that the 2009 Report contained some serious flaws and possible misleading conclusions.   (For e-newsletter subscribers, see my 5-19-09 issue)

Fortunately, there has been an official ACA Reponse to the OIG report which critiques some of the obvious shortcomings of the OIG report that put chiropractors in a bad light.

It appears to be a great waste that the OIG would take the time, money and effort to follow-up on their 2005 report and create such a methodologically flawed document with questionable conclusions.

In addition to the criticisms launched by the ACA in their response (which I encourage you to read by clicking the link above), here are a few examples of the shortcomings that I found as well:

  1. Sample size: IF chiropractic claims represent such a large segment of error-filled submissions that are somehow clogging up the Medicare system, wouldn’t it be prudent to obtain a statistically significant sample size to assess the problem accurately?  Instead, with $466 million worth of chiropractic claims in the system, the new OIG report looked at a mere 188 claims to come to its conclusions.  Since DC’s have one of the lowest $ per claim value in Medicare (since we can only bill for adjustments), these 188 claims probably represent about as statistically INSIGNIFICANT a number as possible!
  2. No Credit for Improvements Made:  Though the new OIG report was quick to point out chiropractic’s poor track record and that chiropractors routinely don’t comply with Medicare requirements, it failed to acknowledge that there was a distinct IMPROVEMENT in % of errors in chiropractic claims from the 2005 report to present.
  3. Skewed Data Pool.  Instead of pulling a random selection of claims (and a larger one at that), the new report specifically weeded out all claims for episodes under 12 visits.  Although the report does not indicate how many chiropractors routinely treat with this visit frequency, this is certainly not an accurate sampling of chiropractic treatment patterns and represents a statistically skewed sample group.

All in all, there are still things to learn from this document – however flawed.

As chiropractors, we still need to take initiative to make sure our billing, coding & documentation are compliant with Medicare or other third party payer regulations.

If we can draw conclusions from this report, it is obvious that we need to be even more vigilant with medical necessity and documentation issues as treatment progresses.

Finally, one item the report did find was several claims with no documentation.  Who knows has this happened, but as a profession we must establish zero tolerance for this type of violation of basic record keeping.

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