In the game Duck, Duck, Goose, you never know when you’re going to get picked, who’s going to pick you, or how fast you’ll have to run! You can probably remember sitting in the circle yourself, being nervous for what will happen next and ready to jump to your feet and make a run for it at any given moment.
No matter the type or style of practice we have, we find ourselves in much the same scenario when it comes to not being sure when or which governing, or auditing-type entity may choose us. Will we be prepared? Will we be able to quickly jump to action and respond? Will we know what to do? Are we paying attention and feeling confident? Cash-based, accepting insurance, or turning away Medicare patients—the risks are still real. Just like the children’s game, every duck is different. Some are fast, some slow, some more intimidating than others and there are those that we hope to avoid altogether. And when you’re the goose, you’d better be ready!
Let’s take a look at just a few of those entities in healthcare that may be just about to reach out and call YOU to action.
Medicare Part B
If you see a Medicare Part B patient, you had better be actively registered with your regional Medicare Part B payer … it’s as simple as that. Chiropractic maintains its position in the Medicare spotlight due to continued concern of fraud, waste and abuse. Medicare has paid more than $450 million per year for chiropractic services since 2010 with an estimated $257 million— $304 million per year of this total dollar figure are identified as estimated overpayments.
Here are the most common reasons for overpayment or mispayment, per findings via Medicare audit:
- Insufficient documentation
- Intentional misuse of the AT modifier to seek reimbursement for services that are not medically necessary
- Billed using the incorrect Chiropractic Manipulative Treatment (CMT) code per Medicare billing guidelines for covered services
- Chiropractors continue to seek the non-existent (and non-compliant) workaround, to avoid Medicare Part B enrollment by asking patients to pay cash, rather than have the doctor bill for active treatment.
Whether you are cash-based, or fully deal with all payers, Medicare Part B is the one entity that you don’t want to run afoul of. Be registered properly with the Administrative Contractor in your region and recognize the rules of medical necessity. Know when a visit is indeed “AT modifier worthy” for reimbursement. Happily charge the patient for your care that doesn’t meet those criteria. It’s simple, but know the rules so you can play fairly and safely.
Medicare Part C involvement is very different from Part B. While it’s still “Medicare”, it may behave very differently in your practice, depending on your in-network status. Verification of these plans is a must.
Traditional Commercial Insurance
When it comes to traditional insurance, practices mustn’t turn a blind eye or act in negligence in terms of documentation, coding and billing for these payors. Don’t be caught unaware, assuming inaccurately that you can’t or won’t be called to action and respond accordingly.
Third-party payors have effective audit and recoupment methods in place and here are just a few of those areas where they’re finding success:
- Documentation is incomplete or not consistent in representing the services billed for
- Service codes billed aren’t appropriately defining the services rendered
- Coding and billing is not consistent with the payor policy guidelines— someone forgot to read the medical review policy
- Providers are performing and inappropriately seeking third-party reimbursement for “unproven (and therefore not payable) procedures”
Understanding Experimental, Investigational, and Unproven Techniques and Procedures
An “unproven procedure” is a procedure which has either not met or attempted to fulfill the rigorous processes and requirements to achieve FDA approval. Often, these are services that are delivered via instrument or machine. Some examples are extracorporeal shock wave, laser, or Bemer mats. Techniques in this category may be a surprise to a provider, when they find them in a payer’s medical review policy as experimental. Some of these are Network Spinal, kinesio-taping, ART (Active Release Technique), manipulation for infant colic, SOT (Sacro-Occipital Technique), and many more.
While these types of procedures and techniques may be effective and beneficial, per compliance, documentation and billing standards, these services are deemed “unproven”. Unproven procedures utilized in healthcare are long and distinguished. Importantly, unproven procedures aren’t often assigned standard and qualified CPT codes for reimbursement, yet too often, it is determined that a qualified CPT code is erroneously assigned to these services and reimbursement is issued to practices. A great example is roller table traction, or a Spinalator, being coded as mechanical traction. It’s not traction, per the coding guidelines.
State Boards
As you’ve read through so far, if you find that you’re breathing a sigh of relief and thinking “I’m a cash practice” or “I don’t do much insurance”, don’t let yourself relax too much. This is a far-too-common misnomer that has found its way into many practices who unsuspectingly are picked to be the “goose” in the game and these practices are often unprepared to respond. Patients (or family members of patients) who find themselves in questionable treatment or billing scenarios often direct their attention straight to your state board with their concerns. Here again, your documentation, coding and billing and overall compliance comes under scrutiny and you guessed it— you’d better be ready and prepared to respond accordingly! State boards can and do take corrective action right to the door of practices!
Can you relate to one or more of these measures discussed so far? Most offices can!
Here’s your next step! Before you find yourself to be the unsuspecting “goose” in healthcare, understand the following:
- A proactive approach is always the best approach (Remember the “duck” that doesn’t paddle is either going to lose balance or sink!)
- You don’t have to do it all alone. Get training and assistance from certified professionals who stand ready to work alongside you to help your practice and your team build confidence and minimize risk!
Don’t find yourself sitting down to a million-dollar game of Monopoly and you don’t know the rules. Your license and your practice are worth gold to you. Protect it and your patients by knowing the rules of the game.
Kathy is a globally recognized expert on the compliance and financial operations of a successful chiropractic practice. With 40 years of service to the chiropractic community, she got her start as a CA in 1983. Since then, Kathy has been sharing her expertise on Medicare, compliance, billing, coding, insurance, patient financial procedures and documentation with audiences around the world. A popular and highly experienced speaker, she has served on many national and state level chiropractic organizations, boards and advisory councils. She is also the owner and CEO of KMC University, which she founded in 2007.
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