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No Surprises

NEW COURSE! | Be Compliant with the No Surprises Act

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OIG

There's no need to fear the OIG. We've got your back!

The most effective chiropractic OIG compliance programs are scaled according to the size of the practice!

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Telemedicine

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Sometimes you need more than a self-service, on-demand program and need an expert to analyze your issues, train the corrections, and help you implement the changes, so they stick

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Your business essentials questions answered

Q: About a year ago we added decompression therapy as a service to our patients. The decompression is strictly a cash service as no insurances in our state pay for it. I'm wondering if we can legally sell the decompression as a package for a flat fee. Also, we are signed up with ChiroHealthUSA and currently decompression is excluded, but would there be a way we could incorporate that if we wanted to sell it as a package?

A: It is strongly recommended that you have written compliance policy that says, “Decompression therapy is always a cash service in this office, never billed to insurance, billed as S9090 (and whatever else applies).” Make sure you charge correctly, bill it correctly, and then collect as you have designed in your financial policy such as in prepayment. You could certainly add this service to your CHUSA fee schedule. Keep in mind that if you create a package plan for patient's that are not CHUSA member, based off of your actual fees, you would have to offer the same package for CHUSA patients based upon the CHSUA fee for this service.

Q: How much should a provider charge for a deposition?

A: We recommend that you consider the time to prepare, time spent traveling to and from the location (if not virtual), and time spent in preparation and follow up. As to the hourly cost, factor what you are making an hour and determine your rate based on the time elements listed above. It is good to ask for payment upfront as you may invest time in something that never takes place. You must consider that you are blocking off-hours that you could be rendering care and earning income.

Q: What is the Q6 modifier used for?

A: When the regular physician will be out of the office for an extended period of time (60 days or less consecutively), the regular physician should make a fee-for-time compensation arrangement (previously known as locum tenens) with the substitute doctor. The payment is NOT an exchange of services but rather a fixed per diem amount. According to Medicare, the substitute doctor does not need to be registered with Medicare to perform the duties of the Locum Tenens (although some commercial carriers (e.g., Medicare Advantage plans) may have different rules. When billing for these services, the regular physicians NPI still goes in 24J and the Q6 modifier is appended. The office needs documentation reflecting the dates that the locum tenens provider was covering and those patients that were treated under his/her care.

Q: When billing for orthotics, should I bill the insurance the day that I ordered the orthotics or the day that I delivered the orthotics to the patient?

A: As with any service or good, the patient, or their insurance, would not be charged until the service or good is delivered. You will often find specific language in payer policy regarding charging for orthotics. For instance, a BCBS plan states, “Coverage will begin on the day the device is delivered to our member,” and “Coverage will begin on the day the device is delivered, setup, and ready for use by the member at the location needed.”

Although Medicare does not cover orthotics when billed by a chiropractor, they provide written guidance on this topic. Medicare states, “The date of service for custom-made equipment is the actual date the beneficiary receives the item. Do not use the date the item was ordered when billing Medicare.”

Q: We use Interferential Current (IFC) in our office and use a new set of pads with each patient. We probably only use it on 20% of our patients. I am wondering if I can bill insurance for the price of the pads or if that is a patient responsibility.

A: You could certainly bill the carrier as with any kind of supply, but it is up to each carrier whether they will pay for the supply code. There is a code called “Electrical Stimulator Supplies, 2 lead, per month (e.g. TENS, NMES) and it’s A4595. It would describe your use of the pads/leads. If you choose to do this, charge everyone the same, and if insurance denies, pass that charge along to the patient in accordance with your payer contract.

Q: Can services of a Physical Therapy Assistant be billed "incident to" a Physician's services?

A: No. The services provided by physical therapist assistants (PTAs) cannot be billed incident to a physician/non-physician Practitioner's (NPP), because PTAs do not meet the qualifications of a therapist. Only the services of a licensed/registered physical therapist can be billed "incident to" a physician service. PTAs may not provide evaluation services, make clinical judgments or decisions, or take responsibility for the service. PTAs act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. The services of the PTA are only billable when provided under the direct supervision of the physical therapist and under their national provider identifier (NPI) number.

Q: When a patient or their attorney requests records in digital format, what am I permitted to charge?

A: The rule of thumb is that you must follow the strictest guideline between federal, state, licensing board, or payer.

As part of the HIPAA HITECH Omnibus, patients (or attorneys) can ask for a copy of their electronic medical record in an electronic format and may use this to get around the copying charge per page.

The Privacy Rule permits a covered entity to impose a reasonable, cost-based fee to provide the individual (or the individual’s personal representative) with a copy of the individual’s PHI, or to direct the copy to a designated third party. The fee may include only the cost of certain labor, supplies, and postage.

The fee may include only the cost of:
(1) labor for copying the PHI requested by the individual, whether in paper or electronic form (2) supplies for creating the paper copy or electronic media (e.g., CD or USB drive) if the individual requests that the electronic copy be provided on portable media
(3) postage, when the individual requests that the copy, or the summary or explanation, be mailed
(4) preparation of an explanation or summary of the PHI, if agreed to by the individual.

The fee may not include costs associated with verification; documentation; searching for and retrieving the PHI; maintaining systems; recouping capital for data access, storage, or infrastructure; or other costs not listed above even if such costs are authorized by State law. Associated Costs Help Under HIPAA, a covered entity can only charge “reasonable” cost-based fees for providing the medical records to patients (see 45CFR 164.524(c)). Arguably, fees that are not cost-based, even if permitted by a state statute, may be contrary to the HIPAA regulation and preempted by this federal regulation.

Q: What is an insurance company looking for when they request records from my office?

A: The most common catalyst for a record’s request is a third-party payer’s pre-or post-payment audit or pre-authorization for requested services. The payer may be looking for many things: proof of medical necessity, improper use of diagnosis or procedure codes, or up-coding/down-coding just to name a few. These requests usually have a deadline of only a few weeks, and the request may include a years’ worth of documentation on multiple patients at the same time.

For the best possible outcome keep the following in mind: Records should be legible, Include everything that is asked for (and any additional information pertinent to the patient's care), be able to support the medical necessity for the services provided, keep the records organized, the doctor should review the documentation before it is returned to the requesting entity. We suggest working with a KMC University Specialist to prepare the records prior to sending them.

Q: Is it better to play the insurance game and take whatever you can get or make massage a cash service?

A: Offices can gain more flexibility by offering massage as an adjunct cash service that is not tied to the chiropractic treatment plan that patients receive. The following outcomes deserve consideration:
• Attract a wider variety of potential patients
• Offer different types of massage such as Swedish, deep tissue, sports massage, etc. without worrying about being able to prove the “medical necessity” of the service
• Massages can be offered outside of normal business hours such as nights and weekends
• Provides an additional source of income that does not rely on the doctor
• Payment is collected at the time of service
• Your price is the price people pay- no reductions for insurance discounts
Deciding to make massage a cash service has major implications from tax, legal, and compliance perspectives. Talk to a tax consultant, healthcare attorney and/or compliance specialist to determine if this option is best for you and to learn how to implement it properly.

Q: What is the benefit of adding a nutrition program to a chiropractic office?

A: Chiropractic and Nutrition go hand in hand. Nutrition services can take a treatment plan to the next level and create additional revenue for the practice. Nutritional services are mostly a cash-based service. However, there are elements to consider for your practice, such as the size of this service to your patients, will you carry the product in house or online, the training of your team and how will these be marketed.

Q: How can we get paid for providing orthotics for our patients?

A: Providers should be aware that even when a patient has coverage for functional orthotics in their benefits package, there’s no guarantee that all orthotics will meet the criteria as a covered benefit of the plan or that of medical necessity. 3rd party payers often develop their own medical policies, which they use to determine their standards for coverage of various products and services. However, never assume that a patient won’t pay out of pocket for orthotics. All patients, regardless of insurance coverage, are entitled to know about the services that can help them achieve their wellness goals. A one-time payment may be hard for some patients; however, there are several other ways to help make this purchase affordable:
• Offer a monthly payment plan
• Use a Flex Spending/ Health Savings Account (if available)
• Use a Discount Medical Plan (DMPO) such as ChiroHealth USA (if available)
• Use a Healthcare credit card (if available)"
"A: Providers should be aware that even when a patient has coverage for functional orthotics in their benefits package, there’s no guarantee that all orthotics will meet the criteria as a covered benefit of the plan or that of medical necessity. 3rd party payers often develop their own medical policies, which they use to determine their standards for coverage of various products and services. However, never assume that a patient won’t pay out of pocket for orthotics. All patients, regardless of insurance coverage, are entitled to know about the services that can help them achieve their wellness goals. A one-time payment may be hard for some patients; however, there are several other ways to help make this purchase affordable:
• Offer a monthly payment plan
• Use a Flex Spending/ Health Savings Account (if available)
• Use a Discount Medical Plan (DMPO) such as ChiroHealth USA (if available)
• Use a Healthcare credit card (if available)

Q: Our staff turnover is continuously increasing. How can we market and hire long term employees?

A: Success and failure of new hires might come down to “cultural fit” — whether their personalities and attitudes fit with office life. Cultural fit also includes the ability of an employee not merely to be able to do the job, but also to have the attitude and personality needed to work with others and further the goals of the practice. The first step for those hiring is to take a look at the practice’s culture. The assessment should include identifying the vision, mission, and values. What is it like to work there? Most practices will say they have a compassionate team atmosphere, but what does that really mean?

Q: Is it better to schedule every visit of a patient's treatment plan, on the first visit, or to schedule them one visit to the next?

A: Scheduling out to at least the first re-examination ensures that your office and the patient will be aware of the re-examination visit. Scheduling multiple visits at one time can ensure the patient's compliance to the overall treatment plan vs. ending treatment once they are out of pain. Typically, when scheduling multiple visits, if you can schedule the patient at the same time for each visit, you will be more successful in fitting the appointments to his/her schedule.

Q: I recently heard Kathy speak about calculating the cost per visit. Why would an office need to calculate this number?

A: Calculating your Cost Per Visit is a great way to determine if you are making enough money with each visit to make your overhead. In calculating this number, you can determine if your Actual Fees or Discounted Fees need to be adjusted. Because variables such as staffing, new purchases (tables, machinery, office, etc), and influx or decline of patient numbers, can all weigh into the calculation of this number, it is important to review this number regularly and stay on top of any adjustments that need to be made to your fees.

Q: How often does our office need to review the fee schedules for the carriers that we are in network with?

A: Medicare publishes new fees every year and most carriers will do the same. However, even if your office is out of network with carriers, it is recommended that you review your actual fees annually within the first few years of operation and then every couple of years after that once overhead, patient capacity and other variables level out.

Q: What do I do if I need to make a change to a patient's record?

A: In order to make an amendment to a patient's record you must have a date of amendment and details of the amendment. You must state that the amendment is an additional record, the date of service that was amended, and the signature of the provider on the original note and the amendment. When making the amendment to paper claims, you must use a single line strikethrough and cannot erase or use correction tape. You may then write in the new information into the record and the reference date. When amending EHR records, this will be a function of the software and you must have a reliable means to identify the original content.

Q: Our office does not do an ROF or FROF. What is the benefit of performing this process?

A: Performing a Report of Findings (ROF) and a Financial Report of Findings (FROF) meeting with your patients will ensure that your patients are well educated, not only about the care that they will be receiving, but also their financial responsibility for that care. Whether your patient has insurance or not, covering with the patient from the very beginning, what the providers recommended treatment plan is, the cost involved, insurance participation (if applicable,) and additional payment assistance (DMPO) options provides patients with valuable information about their care. It also promotes referrals because the patients understand their care and will talk to others about it. This process also helps the patients to remain on their treatment plan because there are no hidden expenses or surprises. It will increase your patients' confidence that your office can assist them with any and every aspect of their care.

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After watching the webinar “Security Risk Management, A HIPAA Requirement”, I went to the government website and spent 4 hours trying to research what I needed to do and had to walk away as I was overwhelmed.  After contacting my Account Manager, and setting a time to review the Compliance materials that are available at KMC University, I now feel this is what I was looking for…simple steps to walk from A-Z.

Amy D.
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