Archive for July, 2009

Audit “Tricks and Traps” DC’s Need to Avoid

by Tom Necela on July 28th, 2009 in Audits, Billing, Business, Coding, Collections, Documentation, Medicare

Reading time: 6 – 10 minutes

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Admittedly, there are some things we cannot do in regards to how the whole health care reform mess plays out.  One thing you can probably anticipate is that if the government gets involved, your level of paperwork, red tape and scrutiny will likely increase. Certainly, this is not good news to any health care provider – regardless of specialty – as most of us feel overburdened by documentation, billing or coding rules and regulations as it is.

In reality, many chiropractors are already getting a taste of what it will be like to be under the microscope.  By now, most states have Recovery Audit Contractors (RACs) – the hired guns employed by Medicare to audit your claims and demand their money back – in full force; the remaining states will begin to get audit requests from the RACs starting August 1.  Yes, that is August 1, 2009, just a few days from now.

As many of you know, I recently became the first and only chiropractor to achieve the designation of Certified Professional Medical Auditor.  In other words, I went through the same training that many of these RACs and most insurance auditors went through to learn how to quickly assess whether or not your billing, coding and documentation met appropriate guidelines and standards and/or was billed and coded correctly.

It was an eye-opening experience for sure and somewhat humbling, as chiropractors are generally regarded as pretty low on the health care food chain.  Anyway, I thought I would share a few “tricks and traps” I learned on my summer vacation with the auditors.

Audit Practicalities and Audit Economy

Most audit tools used by commercial third party payers such as Blue Cross, Aetna, Cigna, etc have a fairly small number of items that are analyzed from a records and/or claim.   The most common number I have seen is around 20 items, meaning that each item is roughly worth 5 points with a couple bigger items worth 10.

The reason for this is both practical and economical.  Practically speaking, if an auditor looks at your records and determines that you have missed 14 or 15 out of 20 items, it is very likely you will miss the same percentage on a larger scale analysis as well.  This also makes good economic sense for the insurance company paying for the audit because this means the auditor can physically perform more audits per hour or per day as opposed to auditing fewer records in more detail.

What this means for you, the target chiropractor, is that you have fewer opportunities to redeem yourself and score points in other areas to achieve a passing grade.  What’s passing? For most Audit Tools that I have seen, a passing score is typically 80%.  So, in a 20 item scenario where a couple items are worth ten points each, you can probably only miss 5 items before failing.

Beware the Low Hanging Fruit

Here is some advice you have heard before:  the low hanging fruit is the easiest target.

You can take this in a couple ways.

First, make sure you never lose points on “silly” audit items – i.e. ones you would literally kick yourself for, if you were to miss.  In this category are things such as Patient Demographics (patient name, address, birth date and appropriate demographic info in all charts) or Confidentiality Measures (HIPAA agreements signed, records releases obtained, etc).  These are items all offices should have in place.

Second, the low hanging fruit is also the easiest target for the auditor.  In other words, if you have been “faithful” in the smallest details, then you are likely to be “faithful” to the more difficult items an auditor examines.  However, if the auditor detects that you have missed even the most basic elements, then you have inadvertently clued them in to the fact that you office is probably unprepared.  Consequently, they will look very carefully at your records hoping to take advantage of your lack of preparation.

Audit Tricks and Traps to Avoid

In offices that fall somewhere in the middle (not totally unprepared for an audit, but not bulletproof either), the auditor must then go to his trusty toolkit of “tricks and traps” to ensure that you do not get a passing score.

While sitting in my auditing certification class, I became a little queasy learning some of their “tried and true” methods for separating the pros from the amateurs. Here is one that has probably knocked more chiropractors down a peg than I care to count:

Documentation of Allergies.

Certainly, many of us have new patients fill out an intake form that asks many questions regarding their health history, one of which usually pertains to Allergies.

But how many DC’s actually spend the time to ask what specific allergies the patient may have?  In defense, most chiropractors would probably state that this is irrelevant to the care of their spine.  Here’s where things go awry.

While it may be true that the fact that a patient who has an allergy has little to do with the safe delivery of their adjustment, it may be extremely relevant to a chiropractor who recommends, prescribes or sells supplements as part of their care.

Take for example, a chiropractor who recommends Glucosamine Sulfate.  Many DC’s routinely do this. Most Glucosamine Sulfate supplements are derived from shellfish. If the DC fails to properly screen for allergies and the patient has a shellfish allergy, he may be found to have substandard documentation. Worse, he may be liable for any potential harmful effects brought on as a result of taking that supplement because he failed to adequately inform, screen or warn the patient of possible adverse affects of taking the supplement.

Remember Whose Game We Are Playing

While this may seem like a strange thing for an Auditor to look for, we need to remember that when we bill insurance, we are playing in the MEDICAL arena.  And for many chiropractors, screening for allergies may have little impact on our documentation or practices, it is not the case for MDs who routinely prescribe drugs that could have serious consequences if allergies were not properly taken into account.

Bottom line: It takes 30 seconds to ask a patient about any allergies.  If you recommend supplements, you should familiarize yourself with common potential allergens that are contained in those supplements and make sure that your recommendations won’t interfere with the patient’s allergies.

And finally, be sure to DOCUMENT that you did this!  In the end, you must always remember, if it is not documented, it was not done!

Stay tuned in the coming weeks for more “tricks and traps” from the Auditor’s playbook.

Until then, keep your spirits up and write it down!

Tom Necela, DC, CPC, CPMA

P.S.  Did you know this information?  From quizzing seminar attendees, I would estimate that 95% of the profession is clueless about most of the billing, coding, and documentation requirements that I teach – despite the fact that some of the info is readily available in coding books, insurance contracts or provider websites (not that anyone has time to slog through all that).  Anyway, this means I should have approximately 50,000 U.S. chiropractors reading my blog and on my mailing list.  As it stands, I am several thousand DC’s short of this several times over.  While you are obviously in the top 5% of chiro-geniuses around (after all, you are reading my blog!), it is probably high time you help a friend, help our profession and send them to my website or blog so we can all continue to help our patients with chiropractic care.  Most everyone loves to receive something for free, especially when it can save their livelihood.  Thanks in advance for helping spread the word and for all your words of encouragement!  It is truly an honor to serve so many devoted stewards of this great profession.

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Mastering Medical Necessity for Chiropractors (Part II)

by Tom Necela on July 21st, 2009 in Billing, Coding, Documentation, Medicare

Reading time: 11 – 18 minutes

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In Part One of this article, we looked at medical necessity “traps.”  In other words, things NOT to do when attempting to document or meet criteria for medically necessary care.

We also discussed that one of the challenges with mastering the maze of medical necessity is that the definitions may vary from payer to payer.  However, don’t lose hope.  There are a few common elements that contribute to most payer requirement.

Here are ones that are often missed, but frequently needed in establishing your care as medically necessary:

B-C-D Matchup. Perhaps one of the most overlooked, yet simple tests for medical necessity is the Billing-Coding-Documentation Matchup.  Essentially, all this means is that you have billed a 98941 then your diagnosis coding must communicate that you have a three to four region adjustment and your documentation must correlate as well.  An auditor who reviews a 98941 claim and detects that only two spinal areas have been diagnosed need go no further: the claim does not meet medical necessity. Similarly, if the billing and the coding match, but the documentation only supports a two level adjustment, medical necessity is also not met.  To prevent this from happening, use claim “scrubbing” software or have your billing personally manually check that these errors do not leave your office.

Response to Care.  Here is another area easily overlooked that can be fatal towards your attempts at proving medical necessity.  Basically, you need to indicate the patient’s response to your care in your documentation.  In doing so, the essential point you want to communicate is this: can an outsider view your treatment notes and get the impression that the patient is progressing, staying the same or getting worse with care.  While it may sound horrifying to report that a patient is worse, reviewers understand that you are not obligated to be a miracle worker. However, a consistent downward spiral would probably indicate your care is not needed, because it is not working.  On the other hand, an auditor does not always assume your care is getting the patient better because they do not have the benefit of being a first hand observer to the patient’s progress, as you are.  Therefore, the best remedy is to always indicate a response to care so that you can clearly depict the results your treatment is getting.

Be Fixable.  A final stumbling block I have observed in medical necessity documentation is the concept of treating a “fixable” condition.  The buzz word “functional improvement” goes a long way in describing how we should approach our treatment and its medical necessity.  Sometimes, this is quite simple.  A patient with mid back pain has restricted motion of the thoracic spine.  The chiropractor’s adjustment restores motion and alleviates the back pain. Certainly this would meet medical necessity in the basic sense.  Now, complicate that scenario by stating that the patient also had severe, longstanding degeneration in the mid back.  Here, the chiropractor may not actually be able to reverse the degenerative process with the adjustment, but the end result is the same: the adjustment improves motion and pain is relieved.  If the chiropractor is able to document the functional losses from the condition at hand and the resulting functional improvements due to chiropractic care, most would agree this meets medical necessity.  While the condition may not be “curable” via the chiropractic adjustment due to the degenerative process, the painful situation the patient is experiencing is
“fixable” and can meet medical necessity if documented accurately.

For many there is a great mystery surrounding the idea of medical necessity.  I hope this article sheds some light on this topic and illustrates how you can properly bill, code and document your care to meet medical necessity.

Tom Necela, DC, CPC, CPMA

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Mastering Medical Necessity for Chiropractors (Part One)

by Tom Necela on July 14th, 2009 in Coding, Documentation, Medicare

Reading time: 13 – 21 minutes

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Eventually, most of us will receive an insurance denial claiming that our chiropractic services were not “medically necessary.” Certainly, this is a frustrating experience. After all, who is more knowledgeable about our patients’ needs than we are? Most of us understand the concept of medical necessity and are aware that our services are reimbursable only when deemed medically necessary.

For Medicare, this means our chiropractic adjustments must be for “active treatment” correction of a subluxation and not for purposes of spinal “maintenance.”

But sometimes medical necessity is a grey area that is hard to completely understand.  The dilemma is due to several factors,  primarily due to the fact that there are almost as many definitions of medical necessity as there are payors, laws and courts to interpret them. Unfortunately, the consequence of failing to meet medical necessity is black and white: denials.

First, the Bad News

So, let’s take a detailed look at exactly what Medical Necessity is with the goal of reducing denials through better understanding.

According to Medicare, medical necessity involves the “diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

While that sounds like a nice tangible definition, consider that Medicare has the power under the Social Security Act to determine if the method of treating a patient in the particular case is reasonable and necessary on a case-by-case basis. Worse yet, even if a service is reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under a national coverage policy, a local medical policy or a clinically accepted standard of practice. Unfortunately, this type of double speak is also readily apparent within the typical third party insurance contracts as well, apart from Medicare.

In plain English, this means is that even though you may have met medical necessity criteria according to some standards, a local medical policy (such as one adopted by your carrier or even your contract) could actually give power to the entity to determine that you have not met all of their standards for medical necessity.

More bad news.

Claims for services which are not medically necessary will be denied, but not getting paid isn’t the only risk. If Medicare or other payors determine that services were medically unnecessary after payment has already been made, they treat it as an overpayment and demand that the money be refunded, with interest. Moreover, if a pattern of such claims can be shown and the physician knows or should know that the services are not medically necessary, you (the lucky chiropractor) may face large fines, exclusion from provider panels, and criminal prosecution.

The “Emotions” of Medical Necessity

When considering Medical Necessity, these two words are certain to arouse strong emotions from most chiropractors.

For some, it is like an elusive murderer on the loose, ready to strike you down when you least expect it. You’ve heard the reports, seen the damage it has done to your community and fear its arrival in your clinic.

Others view Medical Necessity as a challenging summit only a few qualified climbers can actually surmount. You have heard about the requirements it takes; you almost know your efforts will fall short. But you prepare yourself and valiantly attempt to achieve it anyway.

Still others are left completely perplexed by the term.  They are not even sure what Medical Necessity means. They don’t know where to begin or even where to focus attention to improve. They are confused and frustrated.

Then, there are those constantly looking for the ultimate Medical Necessity short-cut. The one size fits all.  The stamp that will win all medical necessity approvals. Do “Step One, Step Two” and it’s a payday homerun for you!

All Players Are Disqualified

So let’s just start by disqualifying all players in the game above.  I’ve seen a version of all of them in my clients and have talked to many DC’s who represent each. Here’s why:

Player #1 is likely to be paralyzed by fear and either will overcompensate by over-documenting for everything he does or will concede that he will be struck down soon and not bother trying.

Player #2 is definitely an over-documenter as well, but he burns out in the process of holding himself too rigidly in his attempts to produce the perfect documentation that will meet medical necessity.

Player #3 is woefully ignorant of any requirements of medical necessity and stabs around in the dark.  He is as likely as a casino gambler to get the “winning” formula for medical necessity.

Player #4 is perhaps the most dangerous.  After he finds the shortcut formula, he repeats it endlessly on all his patients. At first, he succeeds because he actually has met requirements. But because his requirements never change from patient to patient, his repeated submissions eventually show a pattern that gives him away. In time, he either fails to meet medical necessity and/or gets nailed in an audit.

What Medical Necessity is NOT.

In this discussion of how to best meet Medical Necessity, I will end Part One with a brief description of what NOT to do.

Medical necessity is not something achievable in a cookie-cutter pattern. Although this is one of the most common requests I get, there is no “stock” medical necessity SOAP note that you can just “plug and play” to meet medical necessity requirements.  As above in Player #4, even if you could meet initial criteria with your super-replicator medical necessity machine, it would break down as you continued to treat the patient.  As you progress, symptoms should change, objective findings should improve, goals change and essentially the necessity of the treatment will eventually change as well. So simply doing a nice “cut and paste” job will eventually fall short.

Medical Necessity is definitely NOT the same for all insurance carriers.  As described above, medical necssity definitions may vary from payer to payer and on a case by case basis. And you have likely agreed to that fact within your contract. While this is the unfortunate  reality of the game in which we play, we will discuss how the similarities of payer requirements so that you can achieve Medical Necessity in Part Two of this article (yep, you gotta wait!)

Medical Necessity is NOT Related to Your Writing Skills.  Here’s a bit of good news! Certainly some DC’s write a book for every SOAP note visit in attempting to “make sure” Medical Necessity is achieved, but it is not necessary.  Good documentation need not be lengthy, it just needs to cover all the necessary bases.

Stay Tuned for Part 2!

Now that we have touched upon the definition of Medical Necessity and discussed what Medical Necessity doesn’t look like, stay tuned for the next installment when I will lend some thoughts on how to achieve Medical Necessity in your daily documentation.

Be sure not to miss the next segment and do your fellow DC’s a favor and let them know that they need to subscribe as well!

Until next time,

Tom

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Insurers Underpaid ‘Billions’ In Health Claims: What Can We Do?

by Tom Necela on July 7th, 2009 in Billing, Business, Collections, Politics

Reading time: 13 – 21 minutes

The Wall Street Journal recently reported that a flawed payment database produced by a UnitedHealth subsidiary (Ingenix) and distributed to other major insurance companies has led insurers to underpay millions of claims.  The result: patients have been forced to pay amounts they truly were not responsible for to make up the difference of fees that should have been paid to us, the providers.

Aetna, Cigna, WellPoint, and big names in the health insurance field then used the data which was computed by Ingenix to calculate their “reasonable and customary” charges and make them anything but reasonable.

The exact amount of charges deflected to patients remains unknown, but the Associated Press/New York Times reports the number is in the billions, and that two-thirds of the nation’s health insurance industry relied on the flawed payment models.

Of course, UnitedHealth has admitted no wrongdoing in its handling of Ingenix, though it agreed to close the database and help pay for a new one operated by a nonprofit group.”

When you hear about his type of nonsense in the news, certainly it can make your blood boil.  After all, insurance companies already make providers reimbursement challenging while raising patient premiums to capture a larger profit margin in the middle. Insurers make promises they have no intention of keeping, they repeatedly flout regulations designed to protect consumers, and they make it nearly impossible to understand – or even to obtain – information we need.

So how can chiropractors level the playing field when we are dealing with such giants?  Quite frankly, we can’t.  Unfortunately, our numbers are just too small and our pocketbooks even smaller.  But that does not mean the battle is lost, that we need to get out of insurance altogether.

I am a big fan of learning from the successes of others.  In this respect, I believe we can protect our chiropractic interest by modeling what our counterparts in the medical community have done well.

Here are a few things I would propose:

1.      Support Your State and/or National Association.  Best is “and” but if you cannot do it financially, you should at least support one or the other.  While we are too small to fight most big battles, we can enter class action suits and, if we prove a united front, negotiate contracts like the bigger players. One thing’s for certain, a lack of association support will ensure we lose even the smallest of political struggles. 

2.      Raise Your Fees Regularly.  If you were twisted enough to read the actual details of the Ingenix price fixing fiascos, you would have found out that Ingenix created database calculations that automatically and randomly lowered UCR payments.  For example, if you normally receive $35 for a 98940 and an insurer applied the Ingenix database, you would sometimes receive $35 (accurate), sometimes $33 (automatic, incorrectly reduced payment) and sometimes $31 (randomly applied, reduced payment based on a reduced % of your billed charges).  So who could possibly win in this scenario?  Only docs who raised their fees (to help counteract random fee reductions based on % of billed charges) and/or those who paid attention enough to notice the errors and fight it.

3.      Pay Attention to Payment Details.  As in the previous example, most docs (or billing persons) who don’t pay enough attention would never have known that they were being underpaid because they don’t track claims carefully enough (and because the database also shifted payments to patient responsibility!).  Paying attention also helps eliminate unnecessary denials, and coding or billing errors.  Finally, attention to claim detail can also help YOU prevent errors on your part that could trigger audits.  Yes, admit you are imperfect too.

4.      Appeal Incorrectly Paid Claims.  I believe I will have to stop quoting appeal statistics because every time I do, I find another number that is lower.  No matter how you slice it, only a fraction of doctors (of any specialty) appeal claims and insurance companies know it. 

5.      Learn How to Bill, Code and Document Correctly! MD’s know they don’t know how to bill so they outsource it. Hospitals realize that the whole scenario of billing, coding and collections is too vital to neglect, so they outsource everything too. Few chiropractors outsource and fewer take the time to learn how to do things right, even though we admit we were taught none of this in school.  Recently, I ran into an owner of a Billing Company that REFUSES to work with chiropractors for that very reason. Unfortunately, the game has changed.  For those who refuse to learn how to play by the rules, it will have severe repercussions. Those who wish to master the business side of their practice need to keep vigilantly updated on the changes and they will reap the rewards of increased income and protection from audits.

A few additional suggestions:

  • Read the report on the Ten Worst Insurance Companies in America and find out the real gritty details on their practices.  It’s everything I write about and more. Make copies available to your patients so they can quit giving money to these companies who routinely and intentionally shortchange their policyholders and providers.
  • Start Fighting Back: Appeal incorrectly paid claims.  Just a letter will do it in many cases.  If you don’t like writing, check out my Chiropractic Appeals Toolkit for plug and play templates to get you paid!

  • Attend a Seminar or Webinar.  My next one is in Seattle on July 9.  Register online @ www.bowen.us/seminars.  My Seminar and Webinar schedule for August and beyond will be up soon.  The fee is miniscule compared to your return on investment.  Best ROI yet – one doc paid $99 to attend and told me that I gave him a $60,000 ROI by teaching him about just one code he wasn’t using!   I’m no math major, but that ROI is a big number.
  • Get Inspired. Skip the mindless TV and endless drivel that assaults are brain and read biographies or watch films that motivate you to push more for the things you believe in.  In trying times, we need to remember battles that were hard won by those who have gone before us and apply the same principles to the ones at hand.
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