The recent release (July 16, 2010) of the “Final Rule” regarding Meaningful Use criteria and EHR (Electronic Health Records) Financial Incentives has certainly prompted lots of questions from many chiropractors about how to obtain stimulus dollars for their EHR / EMR systems and what they need to do to qualify.
Below is a summary of some key points regarding EHR eligibility for those of you who don’t care to read the original documents or fact sheets on Meaningful Use and EHR Financial Incentives in their entirety:
Meaningful Use Criteria which establish eligibility for financial incentives are for EHR Certified programs only. Translation: if your EHR is not certified, you may not receive any financial stimulus. Many EHR companies are advertising that they are “eligible” for certification, although this is not the same as being certified. Buyer beware!
You know only need to complete 20 of the 25 Meaningful Use Objectives/Measures as defined in the Final Rule issued by CMS. Even though you may “defer” 5 of these requirements, this is still an ambitious list for most practitioners in order to qualify for the funds. (See my previous blog post “The 25 Meaningful Use Criteria for Chiropractic EMR Systems” for a full list of criteria)
The completion of these Objectives/Measures fulfills Stage 1 requirements only (which make you eligible for the financial incentive portion). Stage 2 and Stage 3 objectives exist, but the exact requirements and penalties are not as well defined.
Chiropractors are Eligible Professionals that may qualify for the EHR financial incentives
Chiropractors may be eligible for EHR financial incentive payments as early as 2011; payments can proceed for up to 5 years.
The total financial payments that chiropractors are eligible to receive is a maximum of $44,000 over a 5 year period or equal to 75% of Medicare allowable charges for covered professional services furnished by the chiropractor in an eligible year. This is perhaps the biggest criteria EHR companies fail to mention. In other words, in one given year, you can receive up to $18,000 IF (and only if) you provide at least $24,000 worth of covered services (based on allowable charges) to Medicare patients. On the other hand, if you have a small Medicare practice, your eligible financial incentives will be reduced accordingly and capped at 75% of the allowable charges for your covered services (which, in chiropractic, is CMT only). Do the math to see if your practice qualifies for anywhere near the $44K amount.
The Bottom Line
My final opinion is not changed by the “final rule” criteria. I would highly recommend that most offices switch to some form of electronic health records. However, this advice is NOT based on the presumption that you are doing so to capture any potential financial stimulus incentives. Rather, migrate to EHR because of its potential to improve your documentation, level of care and overall recordkeeping.
I’m on the road for the next couple weeks traveling for a number of on-site consultations with clients so this blog post will be a summary of random thoughts on the most common questions that repeatedly brought to my e-mail inbox.
1) Chiropractic Audits: a few months ago I received a lovely piece of hate mail to accuse me of trying to disproportionately scare well intentioned, upstanding chiropractors in regards to the possibility of an audit. My latest “tweet” included a post to the most recent findings from Medicare reviews for the states of Nevada and Hawaii. In those two states, chiropractic documentation failed to meet requirements 60 to 70% of the time. Similar posts from other review results in the past were even higher than that and OIG reports even higher still.
I might not be the greatest mathematician, but it seems to me that the majority of chiropractors are not scared enough! If 60%+ of chiropractic documentation is substandard, that means most of you are in trouble or headed down the wrong road. It’s not a great picture for me either. There are roughly 50,000 chiropractors in the United States, so that it would be physically impossible for me to help roughly 30,000 of you get your documentation in order, teach you proper billing and coding, or come to your assistance in the case of an audit. I wish that I would live long enough to be able to help, but with those numbers, some of you are just going to have to suffer the consequences.
For those of you who think slightly more highly of me or take the potential of audits more seriously, now is the time to take action. It is obvious to all that audits are a big business for not only cash-starved government entities like Medicare, but also for insurance companies looking to expand profits by taking your money back. The audit numbers and amounts recovered in post-payment demands are so large that they are virtually beyond comprehension for the average chiropractor.
Since I don’t know most of you personally nor do I care to manipulate the facts to scare you, let me just share a few recent scenarios that came by my desk.
Chiropractic Audit case #1: Medicare audit, six patient, 94% error rate determined; post-payment demands made for 18 months (legal limit for that state). Total bill amounts to only a little over $2000. Big pain in the patootie is that this doc failed a previous audit and now has to submit all claims for “pre-payment review” which means that Medicare doesn’t pay him a dime until they receive and approve all notes and every treatment.
Chiropractic Audit case #2: Auto insurance carrier, handful of patients who were treated for the last 3 yrs on claim (bad state, no limitations statute). Total repayment demand is approx $56,000. Legal expenses totalled $8000 so far. Doctor may also face civil fines.
Chiropractic Audit case #3: Commercial insurance. Re-payment demands made by insurance company after extrapolation (process of configuring an error rate to apply across the board). Demand total was close to $95,000. Insurance in error on reviews in some instances and doctor’s repayment will be significantly less, but she will still have to re-pay. Doctor will likely be kicked off insurance provider list as well. Legal fees approximately $17,000.
Maybe this is all chump change to you and you have a life of leisure that can afford the time and hassle it takes to wrestle with the insurance companies, hire attorneys and formulate your audit defense. The rest of you, take note.
2) Business Building: Don’t chase your customers or patients. Find out where they are going and get yourself or your information in front of them. This simple advice (not mine but I can’t remember who I heard it from) is full of wisdom and potential applications. For example, people who are sick or hurting often go to the medical doctor. How can you get the MD to route them toward your office? Most people work. Which of your patients has a position in human resources or is the owner of a small business with a fair number of employees? Rather than try to come up with some fancy high-powered presentation that you will likely work on for the next four years until you’ve whittled it to perfection, why don’t you just approach people who already know and trust you as patients and see if they can help you make inroads into their company? People surf the Internet. First off, that means you need to have a website too. While the chances of catching random visitors that become patients are slim, but you can stack the deck and give them a reason to come to your site by writing articles, posting videos, and providing other informative content for your community.
Obviously if you are busy enough, you may not need to employ any or even all of these strategies. But for the rest of you, instead of spending time surfing the net do something tangible to improve your web presence. Rather than whining that referrals are down, take a concrete step towards leveraging your patient relationships to increase your referrals on your patience. Instead of sitting in your office hoping patients will come to you, reach out to where they are and bring them in.
3) Success. Keep in mind that your business should be there to serve you and not vice versa. I’ve run into too many chiropractors whose primary purpose seems to be providing jobs for their employees. Worse, I’ve seen too more “successful” chiropractors whose drive to succeed left their spouses, children, health and sanity by the side of the road. A few fortunate ones can come back and retrieve it. But for many once these items are lost, they are gone forever. Take a day off and go play while the weather is nice. Spend the afternoon with your children, the evening with your spouse. Your bank account may not look immediately better for it, but in the long run it is cheaper to stay married, stay healthy, stay sane and not have to pay for years of therapy for your screwed up kids!
As for me, I intend to practice what I preach both working and playing. If you have an Audit or business issue to discuss, feel free to drop me an email. That’s the beauty of the internet, it can be checked anywhere. On the other hand, if you see a bald man not acting his age on a wakeboard at a lake near you, it just might be me
Last year, I posted an article on co-pays, coupons, and discounts – essentially what to do and what not to do.
This subject remains one of the most popular questions I still get asked.
As we recently have celebrated the freedom of the USA with Independence Day, I thought it fitting to re-visit the “freedoms” (or lack thereof) that we are challenged with inside our chiropractic practices.
Unfortunately, when freedoms are abused, trouble sets in. Keep your nose clean and re-visit the post
In case you haven’t heard, two recent legislative changes have been passed that will affect you as a chiropractor:
Because these changes (or non-changes) happen quickly, I typically alert chiropractors of these via my Twitter page. But for a change of pace and because I know 14, 238 of you reading this are NOT following me on Twitter I thought it might be useful here as well.
(BTW: If you are on Twitter, no worries. I won’t send you tweets about what a great lunch I am eating or give you my reaction to the latest celebrity gossip in 140 characters or less. If you are not on Twitter, it’s a quick way to stay updated on changes in chiropractic that you need to know. Plus, as a special bonus, you can re-tweet them (sort of like an email forward without the bad jokes) to friends and impress them with you ability to stay in the know on current events!)
So, here’s the news:
Medicare Fee Decrease
The long-anticipated (dreaded?) 21% Medicare fee decrease is scheduled to go into effect June 1, 2010. While hopes have been high for a delay, no final Congressional action has yet been taken.
Medicare recently released a notice indicating that they would hold claims for the first ten business days of June to provide Congress with additional time to consider this issue.
Chiropractors should be aware that this hold will only affect claims with dates of service June 1, 2010, and forward.
Claims paid prior to June 1 should still be paid at the zero percent (0%) fee increase proposed by other recent legislative activity. Translation: claims paid with dates of service Jan 1 through May 31 will be paid at the same fee schedule as your 2009 rates.
Red Flag Rules Delayed
Again, the Federal Trade Commission (FTC) has delayed implementation of the Red Flags Rule. The next date is set for January 1, 2011. Although it has been a subject of much debate whether this ruling even applies to chiropractors, no worries – you still have time. Meanwhile, Congress intends to determine the scope of entities who are covered by the rule. We will just have to wait and see how that turns out.
Hope you had a great holiday weekend!
I will be back next week with my usual fare of musings on all things related to the business of chiropractic.
Apparently, last week’s blog post on security struck a sore spot with many readers who have experienced security problems, challenges and employee issues within their office.
Interestingly enough, the comments and questions I received were not focused on firewall breaches, corporate bank data comprises or any “high level” security threats that created a cascade of financial and stress-related nightmares for chiropractic offices. Instead, most of your comments could be summarized with two warnings:
1) Beware the low-tech hacks
2) Employees can be incredible liabilities if not managed properly
While most would probably agree that any security issue should be approached with sufficient planning and preventative measures, the stories of just how much trouble these two items caused for your fellow chiropractors was both surprising and seemed to warrant additional attention on the matter.
Let’s deal with the first topic:
Beware Employee Stupidity and Low Tech Hacks
While the thought of some financial terrorist attempting a transfer from an entire bank’s portfolio of accounts to a mysterious bank in Liberia or the possibility of a band of Bulgarian mobsters launching a viral shutdown of your town’s financial institutions is certainly upsetting, apparently it’s the not-so-flashy stuff on which we should focus our preventative measures. Similarly, while some of you may lose sleep at night for fear of violating the umpteen HIPAA regulations you didn’t know about, it’s the stuff that just makes plain common sense that you can easily prevent.
An apparently, these common, everyday issues are thwarting your fellow DC’s.
For example:
Last year about this time, big trouble broke out in Tennessee when thousands of medical records – including patient photos, files and social security numbers – were found in a Chattanooga recycling center bin. You need not be an expert in all matters HIPAA to determine that dumping your records (old, new or even patients that you do not like) into a recycling bin is not the proper way to dispose of medical files. Yet, it happened and the news was all over the story. And I am sure the fines weren’t pretty.
What’s worse is that the guy caught dumpster diving for those files (who likely thought he hit the mother lode of his career) took those files to make 1000 fake ID’s in which he ripped off other people, stores and banks. And he committed similar crimes throughout California.
I am sure you can also see several problems here:
This fella was not just looking to be the most popular guy in his high school and make fake ID’s for all his friends to get into the local bars. He is stealing your patient’s data as the starting point for his criminal sprees.
Apparently, banks have poor protective mechanisms for detecting fake id’s
Unlike banks, YOU as the chiropractor are dealing with Personal Health Information which means when someone like this steals your patient’s info, YOU are now required to report the breach
The process of reporting to Mrs. Melba Johnson that one of your employees (I am assuming it wasn’t you who dumped the files) used poor judgment and put her file in a recycling bin and some thief came and stole her social security number and other personal information and by now, has applied for an Abercrombie credit card, a home mortgage and was approved for a $1500 credit line to purchase some new wheels for their new/used Mazda (also purchased via the kind donation of Mrs. Johnson) – this is a conversation that will not go smoothly.
This conversation will need to be repeated with all of your patients whose records were breached
Silence is Golden
Sometimes privacy or security takes the simple form of silence. Unfortunately, according to my mail bag (actually e-mail inbox, but I always thought it would be fun to open a bag full of fan mail) silence is not so simple. Employees routinely assist you in violating HIPAA privacy policies by openly discussing patient information with…well, anyone!
And while this too may seem like common sense, again, see above. It’s not usually the stuff out of The Matrix that is going to foil you. But when your employee casually mentions in the grocery store that she has seen Mr. Weasly in your office, not knowing that Mrs. Weasly has been trying to chase him down for 7 months worth of alimony, suddenly you are amidst a family squabble AND your employee’s loose lips have sunk your HIPAA ship. Mr. Weasley may be forced to pony up on his alimony but you will be footing the bill once he turns you in for violating his privacy.
Similarly, it may seem like you can safely assume that the 16 year-old your tech is about to x-ray is not-pregnant, has their parents permission or even has parents that are paying, none of this is safe. And when your staff member e-mails the x-ray results to her parents, questions abound that you do not want to answer.
Silence is golden, if you can get it.
Some Employees are Smart, Lazy and Vindictive
Judging from the responses I received in regards to employee security threats, not all employees are dumb enough to dump data in dumpsters. In fact, some employees are too smart for their own (or our) good.
They play endless rounds of computer solitaire while claiming they don’t have enough time to do their job. They surf the internet on your time and your dime. Literally – you pay them and some of them shop for personal items using your credit card. Others make money by selling your patient list to direct mail marketing companies. And when they leave or you fire them (associates or other independent contractors), they attempt to take your patients (and sometimes your records too) with you. Then, they try and sit on unemployment for a year and half (despite the fact they only worked for you for a week and a half!).
Learn from the multitude of chiropractors who wrote in asking how to prevent these exact situations that occurred at the hands of wasteful or rogue employees. Protect yourself from unanticipated emergencies (let’s face it, no one’s smart enough to predict this type of behavior predictably).
Here are Three Protective Agreements I think can prevent a multitude of the problems many of you are facing or have faced in the past:
1) Establish an Employee Confidentiality Agreement: While might seem basic to have your employees sign something that states they can’t blab info or dump data, but if it occurs, you have at least protected your end from needless additional punishments or penalties via HIPAA or the consumers. Also, you need to demonstrate ongoing training in these matters, so having employees sign such an agreement (along with actual training) provides a paper trail of your compliance in this regard.
2) Utilize a Non-Compete Clause for All Associate Doctors: Sure, it may work out. You may even be partially at fault if it doesn’t work well. But protect your practice and livelihood if it does not. Some states limit the usage of these agreements, but in general, something is better than nothing. And I have witnessed the successful enforcement of non-competes which served their legally binding purpose along with stiff financial consequences for their violation.
3) Establish Appropriate Technology Policies: I use the word “technology” because really you have to have written guidelines for proper usage of the internet, of computers (and passwords), of cell phones, voice mail, email, downloads, instant messaging, etc. The least of your troubles (but the most common) is employees wasting time while surfing or emailing for personal reasons. As above, it can get a whole lot uglier than that, so to prevent this, put a policy in place!
Hindsight is 20/20 Wisdom
According to every chiropractor who e-vented (vented via email) their security and/or employee problems, you will undoubtedly and repeatedly kick yourself for future fiascos in this department – especially after reading this blog and being warned! Skip e-mailing me about how ridiculous it is that we have to do this and how deplorable society has become. I agree and the entities that make these rules don’t care. You just need to protect your asset numero uno.
Here are your options:
Have your attorney draft the Three Protective Agreements for you and sleep soundly knowing you’ve done your part.
Search the internet for these agreements – make sure they are up-to-date! Most technology agreements, for example, that I have seen online are outdated either have no reference to what we do as chiropractors (translated HIPAA!) or do not contain clauses for relatively new “social media” provisions, online downloads policies or even instant messaging.
For those who’d like to save time and searching, you can obtain a copy of my Three Protective Agreements that I use with my clients, updated and ready-to-go. Simply, open the Word Document, change the names and any relevant info to your clinic and you are on your way! For those who would like to have an attorney review your document, this will save you time and money from having them draft one from scratch.
Anyway you slice it, be sure to act on this promptly. While both crime and stupidity are unpredictable, the price of planning is not nearly as painful as the headaches and hassles that will occur as a result of your neglect on this!
To Your Success!
Tom Necela, DC, CPC, CPMA
Legal Disclaimer: Every reasonable effort has been made to ensure the accuracy of the information and recommendations provided in respect to these Three Protective Agreements. However, due to the nature of changing payer requirements and state regulations, you may wish to seek advice from a local health care attorney to ensure that the use of these agreements are legally valid and compliant with your state laws.
Today’s post is a back-to-basics reminder of something that we all should not need to be reminded of, but….it is likely than most chiropractors could use improvement in this area.
The topic: security.
Specifically, I’d like to say a few words about the security of information, finances and records in your office. Some of this pertains to HIPAA; some of this pertains to good old fashioned common sense. Both are needed.
In case you were not aware, business accounts are the most vulnerable to hacker attacks and the least protected by the law. This is bad news for all chiropractors who do not hold their money under their mattress, which I suspect is most of us. Here’s why:
Hackers are much more inclined to break into a six-figure business account than a consumer account with a few thousand dollars, according to the article “Could Online Hackers Steal Your Cash” published on the financial website Bankrate.com. And there’s more bad news: if your bank determines that your money vanished because of something you did, they may not be liable for your disappearing cash! Sound a bit subjective and risky to you?
With online transactions and banking opportunities increasing daily, chiropractors need to be especially vigilant of protecting their accounts not only to protect their money, but need to take extra steps towards data security in general. A breach in a health care office may not only be financially damaging, but also has potential to cross lines and expose patient’s personal health information, which could lead to HIPAA privacy violations and fines as well.
While all of this may sound like the plot line to a new conspiracy theory thriller, a quick reality check in your own office may reveal that you are either well protected or unnecessarily exposed so such dangers.
Here are a few items that I would recommend for your to-do list so you can sleep a little more soundly:
Make sure all patient files (and x-rays) are kept in locked storage. This is not only required via HIPAA regulations, but is a good idea to prevent theft.
Utilize tougher passwords online. “1234” just won’t cut it. Use multiple passwords – not the same one for every site to avoid a widespread breach. Mix upper and lower case numbers, letters, symbols, etc.
Protect yourself against malware (viruses, spyware and other online threats). While most computers come with a free trial, many chiropractors let them lapse and/or never upgrade to the full version. Check out the June 2010 issue of Consumer Reports magazine for the latest ratings on effective free and paid security software. The most expensive fee of any of their recommended options is $70 – hardly a matter for debate when you consider the amount of time, money and effort that will be expended if something bad happens.
Pay to have a security system with monitoring installed in your office. In terms of banking, your greatest theft threat may be online. But fire, break-ins and other hassles can effectively be monitored via a security system. I know several DC’s whose offices were destroyed by the elements and many more who suffered break-ins. Even small town DC’s are not immune to crime and certainly not safe from the elements.
Don’t Let Employees Take Laptops Home. One of the biggest data breaches in health care history occurred when a Blue Cross employee took a laptop to do some work from home. Unfortunately, the laptop was stolen in a parking lot while the employee was busy running errands. So not only did the employee NOT get any work done at home, the employee inadvertently caused a data breach that involved over 100,000 physician records – including Social Security numbers and EINs. Certainly, an accident like that would not be of the same magnitude for your office. But how many patients do you want to notify and inform them that your employee’s conduct caused their personal information to be stolen? Although that would certainly not be fun, it would be required per HIPAA regulations and failure to do so would result in major fines!
In business and in life, it is helpful to go back and review the basics, to take a look at where you’ve been and where you want to go.
Today’s blog post feature’s 3 links to our most popular columns of the past – in case you missed them – or in case you need “a refresher course.” (pardon the Fletch reference)
Don’t Panic and Don’t Ignore It! An audit letter is not an automatic presumption of guilt. Some audits are completely random and conducted routinely with no suspicion cast toward your billing activities, documentation ability or treatment parameters. So do not panic in the presence of an audit letter. Don’t assume that your documentation is substandard. Don’t automatically determine they will find your records insufficient and make plans to be subversive. On the other hand, do not ignore the audit letter. Instead, plan to take action.
Can I even be audited? You do have legal rights depending on the state in which you practice and your specific situation. For example, if you are an out of network provider, there is a possibility that the carrier cannot audit unless they suspect fraud. On the other hand a governmental entity like Medicare definitely can audit you, so move on to the next step. Perform your due diligence immediately and research this issue.
Determine exactly what the audit letter states. Are they requesting a chart audit where they want to look at your medical records? Do they want to perform a site visit? Once you’ve determined which type of audit they’re intending to conduct on your practice, you need to formulate response to that audit or to the request that the audit’s making in a timely manner. In some types of audits, no answer is the worst possible answer you could give. So you want to respond in a timely manner to the request for the audit. Also, provide what is requested: nothing more, nothing less. The auditors do not want to review a 42 page explanation of your chart notes; they should stand for themselves. Furthermore, any additional material you provide beyond what is requested can be used against you as well. One tip: do not respond to phone or fax audit requests. Get it in writing!
Do Not Alter Your Documentation. I get many emails and calls from chiropractors who have received an audit letter. The most common question is: “what do I need to do to prepare for this audit?” To be blunt: the time to prepare for your audit is not when an audit request letter is in your hands! Never take matters into your own hands and alter medical records to improve what appears to be incomplete or insufficient documentation. Poorly done records are still better than the best records that have been fraudulently contrived.
Determine IF You Can Meet Audit Requests. If the time frame that the carrier is requesting is not reasonable due to some sort of extenuating circumstances, contact the auditor for an extension. If it’s going to take you more time to produce the information, ask for an extension.
Is this something we need to appeal immediately? If your “audit” letter is actually a demand for repayment, your best option may be to start the appeals process. Do not automatically presume that the payor’s review is final or even correct. If appropriate, an appeal can save you thousands of dollars in unnecessary repayments and headaches.
Is this something for which you will experienced assistance? You may need to obtain the assistance of a certified professional coder or a certified professional medical auditor whose expertise is in chiropractic (such as myself) to help defend you. A healthcare attorney may also be wise, especiallyif there are several zeros in your demand or repayment letter. Again, before you hit the panic button or get out your checkbook, it may be critical to the success of your defense or appeal to get professional help. The reality is that your license, your lifestyle and your livelihood may all depend on it!
I hope that you found this article helpful. For a more detailed discussion on audits, I suggest you check out my program “How to Prepare Your Chiropractic Practice For Recovery Audits.” For specific questions regarding your own audit situation or letter, you may contact me per the guidelines below.
Due to the large volume of requests that I receive for audit advice, opinions and requests from chiropractors to “look this over and tell me what this means,” I can no longer respond to phone inquiries on this matter. If you have need for an opinion or objective discussion on audits or demand letters, the need for attorney/ legal representation or appeals, please contact me via a separate email for this purpose at Audits[at]StrategicDC.com.
Just in case you were actually focusing on your practice and not glued to the news, HIPAA television and the endless assault of compliance related emails that cross your desk, we had three significant deadlines in February that seem to have rattled a significant number of you.
Even though I may not know you personally, I am going to extend you the grace of assuming that you are not normally paranoid, panicky or otherwise possessive of a peculiar tendency to “snap” when confronted with the politics of change that besets our profession.
So, let me first gently remind you of the deadlines of which you may or may not be aware. And then, I’d like to put your mind at ease over a few items that repeatedly hit my email inbox and drip with panic-driven sweat and media-fueled fear.
The Deadlines
New requirements for “Business Associates” – Deadline: February 17, 2010 HIPAA rules were strengthened by extending the responsibility for protection of PHI to “Business Associates.” Under the new law, the “Business Associates” have the same responsibilities for any breach of private health care information as do the provider of the services. “Business Associates” would include Attorneys, Consultants, Accountants, Third-Party Billing Companies, Computer Vendors or maintenance companies, etc.For a more detailed description of this requirement, see my previous blog entry on “Mandatory HIPAA Updates.”
Disclosure Agreement Provision – Effective: February 18, 2010
Patients have the right to pay in full for out of pocket expenses for health care services and request that your practice not disclose his or her medical information to a health plan or other entity. Your practice must comply with this request. Make sure that all your employees are informed about this provision and modify notification or follow-up procedures where applicable. This is information that will have to be shared with all employees in the medical practice that is involved in health information and insurance processing. This one is not likely to happen too often, but regardless, you are still required to follow the rules should it occur. Essentially, if you have a patient that is under- or non-insured and pay for services in cash (or credit card, check), they have the right for their info to remain silent.
Information Breach Notification – Effective February 22, 2010
New provision requiring that HIPAA covered entities such as physicians notify patients (and Business Associates notify the partnering entity) of any breach of health care information. If a breach involves 500 people or less, the responsible party must notify each affected individual by written notice. This notice must contain the details of the breach, the information disclosed, and the steps being taken by the practice or entity to avoid any future breaches, as well as explaining the rights of the patient(s) in protecting their private healthcare information. If the breach involves more than 500 persons, the Act requires that the Department of Health and Human Services be notified as well as the local media outlets. Hopefully, this one will never happen, but you should be aware that if it does, there are required steps to take.
The Reality of the Situation
Of those three new HIPAA requirements, I do not see any as the reason to hit the panic button. Rather, get your Business Agreement in place and train the staff on the other two, should the need ever arise.
As for other recent news affecting our practice (and for which I received a lot of email), the President did signed into law a bill that delays Medicare Fee cuts until March 31, 2010. Hopefully, this delay will be prolonged at least until 2099 or until the government gets its Medicare act together, in which case the 2099 date may happen first. On this item, continue to make your voice known through your state and national associations and hope that we make enough collective noise to stop the feds from cutting our paychecks.
Again, no need for panic, but action may be helpful.
Some FAQs About Chiropractic Compliance Measures
The one interesting byproduct of chiropractors who begin to get their compliance act in gear is that more questions begin popping up over everyday matters. Suddenly, policies and procedures they have utilized for years become the subject of much questioning, much needed revision and, in some cases, not so needed fear.
To set the record straight, here are a few items that I would like to clarify for you so that you can fully understand your responsibilities and which side of the compliance fence that you stand.
Q. Our practice confirms patients’ insurance coverage by contacting their health plans the day before their appointments to verify coverage and patients’ financial responsibility. Do we need their consent or authorization to contact their health plan?A. Patient consent or authorization is not necessary to disclose PHI for coordination of benefits, which is considered part of your treatment. Per HIPAA [45 CFR | 164.501] the full definition of treatment includes: “the provision, coordination or management of health care and related services by one or more health care providers, including the coordination or management with a third party
Q: Are sign-in sheets or calling out the next patient’s name in the waiting room – allowed or not allowed?A: Yes, they are allowed. Believe it or not, if you actually sit down and read through the HIPAA regulations (sick and twisted) one of the intentions behind HIPAA that you will repeatedly see mentioned is “administrative simplification.” To this extent these activities result in other people learning a patient’s name or other information, the disclosure would be considered “incidental” to your of the patient, and therefore acceptable under HIPAA. (7.6.2001, OCR HIPAA Privacy TA 164.000.001 FAQ) Chiropractors should still take appropriate precautions to limit the amount of information that might be incidentally disclosed in this manner. For example, you may not want to ask patients to list “reason for visit” on a sign-in sheet. With respect to placing charts outside of your adjusting rooms, you should take precautions such as turning the front of the chart towards the wall so others do not have the opportunity to read the front page while walking past the room.
Q: What about billing electronically, EMR and all these new proposed regulations? Am I going to be required to do all of this?A: While it may make sense for many individuals to move as much as their practice as possible to an electronic format, you have two reasons to rest easy. 1) Several proposed requirements for electronic communications are still in the future and so there dates may be delayed or never quite arrive. 2) You may be an exception to the rule anyway. For example, back in 2003, providers were supposed to be required to bill Medicare electronically. However, this requirement does not affect many chiropractors, as there are exceptions to physicians with fewer than 10 full-time employees. [42 USC | 1395y(h)]
Keep informed so that you know what you are required to do, but don’t get paranoid. Focus on your practice and your patients. Sleep easy.
In the wake of insurance denials, some chiropractors pose an interesting question in their attempt to get paid for what they do. It is some variation of this:
“If I billed something incorrectly…or the insurance company denied a particular service…or procedure A was bundled with procedure B…can I change my records/billing/coding so I can get paid for this?”
Certainly, my loyal blog readers know that one of the two primary purposes of my writing this column is (1) to help you maximize reimbursements by getting you paid for ALL the work you do. But this purpose is also coupled with keeping you compliant in your billing, coding and documentation while attempting to achieve my other goal for you, which is (2) to minimize your audit risk.
In other words, I would love to see every chiropractor paid well for all of the work they do (not more than they deserve, but not less) and, of equal importance, possess the proper documentation necessary to KEEP the money they earned.
Answering the question(s) posed then is not a simple “yes” or “no” but an “it depends.” Let’s explore this a little further.
Amendment of Records Can Be a Good Thing
Amendment of a medical record can be a good thing. Reviewing your records to check for accuracy and completeness and taking the time to amend them is common and commendable. We all know that the daily duties and pace of practice often cause us to spend less time taking notes that we may want to or that good documentation may warrant. Therefore, a practice of reviewing notes before the day’s end, for example, can be a good way to catch any missed items needing documentation as well as prevent incorrectly billed or coded services.
Obviously, the best practice is to complete your records correctly the first time. But if you didn’t, you can make an addition or correction later. You must do so in a legitimate and above-board fashion—timely and not apparently an “alteration.” Different payers may have varying definitions of what constitutes “timely” documentation, but most appear to indicate that the note should be completed during the actual encounter of shortly thereafter. Most payer descriptions I have seen of this seem to indicate “shortly thereafter” means within 24hours after treatment.
Avoid Alteration of Records
Let’s differentiate between the terms: “Amendment” or “Alteration.” For our discussion, Amendment refers to the process of reviewing and/or correcting mistakes within a short period of time (as above) for the purposes of correction. Alteration, on the other hand, does not quite convey the same corrective intent.
For example, if you alter your records once a lawsuit has been filed or an attorney has requested your records, it’s too late and this would not be considered a legitimate “correction” or amendment of the patient’s file.
Unfortunately, this is a common scenario: you receive a request for records, review your documentation, and see that some fact is omitted or some entry is inaccurate. You quite innocently think that you can “improve” the record.
Let me stop you there. Don’t do it.
Every state chiropractic board in the country has heard numerous cases of records alteration and, I am sure, cringes every time they have to review one.
In reality, the insurance company, plaintiff’s attorney, claim review company and who knows who else has likely already obtained a copy of your records in their original form. As the jury is shown both the original record and your “revised” record, you will see your credibility disappear before their eyes – even if the alteration of the record was innocent, helpful or minor.
At the least, any alterations you make in the records significantly after the treatment date can be viewed as self-serving. Taken to the extremes, it can also be regarded as a cover-up or potential fraud. (See picture at start of blog for what technology can do to squash your attempts to alter records anyway!)
Adding To or Correcting Records
What should you do if you discover an omission? Suppose you review your earlier progress note and discover that you forgot to state that you made an appointment for a patient x-ray? Or what if you reviewed the x-rays and in the process of documenting your findings, inadvertently left a key finding out of your report?
Sometimes, omissions may not have clinical relevance but are needed for accuracy. For example what do you do when you discover that a simple typing error has made your 26 year old patient 62 years old?
In cases like these, adding a note can illustrate the fact that you are a conscientious chiropractor by demonstrating that you are careful enough to review your notes and concerned enough to add the missing information.
To properly amend records, you need to:
Put a notation in the margin next to the original entry: “see my note below.”
Enter another note at the time you discover the error. Write in the added information. Initial and date it.
Draw a single line through the incorrect entry. Make sure that the original entry is still legible.
Explain the correction. If possible, explain why the earlier note was incorrect, the reason for the error, and the reason the error was noticed.
On the other hand, erasing, using correction tape or fluid, or obliterating any documentation in the record is unacceptable and would be a big no-no that can land your tail in hot water.
Billing Snafus
Many chiropractors contact me – after the fact – about their claim denials, payment disputes or billing problems which may have occurred as a result of errors or ignorance. Some of these problems are correctable.
If you legitimately performed a procedure, documented it correctly and simply forgot to bill for the procedure alongside the other services that were rendered during that visit, you may wish to submit a corrected claim and get reimbursed for this. Provided you do this in a timely manner, the insurance should reprocess the claim and pay for your for the service.
Similarly, if an insurance company has denied your service based on a claim submitted with the wrong code on it (due to a human error, mistake, number dyslexia, etc), re-submit your claim for payment consideration. In these instances, I find a short letter submitted with the corrected claim to be helpful. (i.e. Dear Sirs, I inadvertently billed for 58940 instead of a 98940. There was no Oopherectomy performed, in part or total, during the course of the patient’s chiropractic visit nor was it my intention to attempt to get paid for one. The service performed was…)
Some billing problems, however, should not be corrected.
For example, adjusting 3-4 areas of the spine (98941) and performing manual therapy (97140) in one of those same areas won’t fly with payers and will result in a denial. If you have billed this out and find a rejection letter staring you in the face, you should not downcode your service to a 98940, re-bill it and hope to be paid for your “corrected claim.”
Presuming you did adjust three or four areas in the first place, it would be fraudulent to downcode because you are essentially lying to get paid. Again, take your lumps and correct the issue.
Likewise, if you bill for a service only to find it denied, you should not re-submit the claim using a different code in an attempt to get paid. Look in any coding book, page 1 or thereabouts and you will see instructions that read something like “Select the name of the procedure of service that most accurately identifies the service performed.”
Spaghetti billing methods (throw it to the wall, see what gets paid/sticks) are not advisable, inefficient and potentially fraudulent.
Parting Words of Wisdom…From Bob
So what do you do if you have a billing problem that causes you to lose money, but which you cannot correct if you wish to keep your nose clean?
Identify and research the issue so that you can understand the problem.
Seek experienced help. Billing and coding errors rarely occur in isolation. Typically, I find multiple errors that are costing my clients thousands of dollars in unrealized income or potential losses.
For future purposes, and on the lighter side, see Bob Newhart’s classic advice on the matter below. A little on the rough side, but technically accurate! J
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