Consistent Compliance = Regular Reimbursement

Whether your office has been open for more than 20 years, or you’re about to hang your first shingle, consistency, systems, and accurate compliance should be your watchwords. Creating consistency in the systems you put in place is easy, but compliance can be complicated, overwhelming, and confusing. It is not surprising that many doctors zone out when they hear the word “compliance.” Practitioners would be wise to mix these compliance components in the cement that will hold the practice together. Additionally, any doctor opening a satellite office must be sure that the systems used in one office are seamlessly duplicated in the new office.

We will discuss the most critical pieces of information that every chiropractic office must implement. Keep in mind that if you treat Medicare patients, you are accountable for all the rules of compliance we are discussing. These rules often cover every financial encounter as well.  Review this list and appraise your level of consistent compliance. If you find any weaknesses in your systems, confusion in your understanding of the rules, or concern that you may not be completely compliant, act now to get it corrected. You will sleep better at night and be able to put your concentration where it should be – helping more people with the power of chiropractic care.

To Join or Not to Join

If you plan to enter the land of third-party reimbursement, whether Medicare, commercial health insurance, or personal injury, be sure you clearly understand whether being in or out of network is your best choice. As a new practitioner, you may think it’s imperative that you join every major insurance network that your patients could potentially belong to. Don’t make the incorrect assumption that patients will only come into your office if you participate in their network. Do the research to make sure the network you are considering is worth joining.

There are many things to consider before joining a network. Among them are the levels of reimbursement you can expect, the restrictions placed on the practitioner’s ability to balance bill the patient, and the definitions from their medical review policy that will be applied to your treatment. You must read the provider’s agreement and understand every stipulation that you are agreeing to with your signature. Far too often, doctors find out well after the fact that a procedure regularly performed in the practice isn’t covered or is bundled per the contract. Additionally, providers may choose to add a new service or product, such as spinal pelvic stabilizers, and find that their provider agreement allows for reimbursement at a level lower than the cost of the product. If you plan to join a network, you will be required to follow every rule of the agreement you signed.

Know How to Define Medical Necessity

One of the most important building blocks of consistent compliance, if you are dealing with third-party payers, is to understand their definition of medical necessity. To fully apply these principles in your practice, you must understand the difference between what is clinically appropriate in your mind and what the carrier believes is medically necessary. Most often this definition is in writing in the medical review policy. With Medicare, it is clearly laid out in the Local Coverage Document from your Medicare carrier. The definitions of acute, chronic, and maintenance care, and of medical necessity, can be the most important information items in your toolbox. Ensure that you are only submitting billing that is clearly in line with both your agreement and the medical review policy of the carrier. If there is a discrepancy, they won’t tell you that you can’t treat the patient, but they will expect the patient to cover the cost of service out of pocket.

Never Give Away Services

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

Compile Office Standard Operating Procedure (SOP)

Written operating procedures provide a valuable protection for a practice. From a consistent compliance standpoint, your written policy and procedure manual contains your declaration of the way you intend to follow the rules. From a practical point of view, this manual also details every procedure performed in the practice. If a team member leaves, all of your institutional knowledge does not walk out the door with him/her. Rather, the written detail of how your practice runs, down to the step-by-step procedure for entering a patient payment, is safely tucked away in your procedural manual for anyone to follow.

With important policies and procedures in place, deviations from them could be seen as errors rather than as a pattern of abuse. For this reason, new practitioners must begin compiling this important manual immediately. Those who plan to open a satellite office should make sure that their original office is fully operational with procedures in writing before ever attempting to open another office. This ensures consistency and compliance.

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