n March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act. This law puts in place comprehensive health insurance reforms that will extend for four years and beyond. The vision and timeline seem daunting, from the 2010 inception of a new patient’s bill of rights to the 2014 goal for all Americans to have access to affordable health insurance options. The new law raises questions, such as: What will be the impact to patient care, clinical decision-making, documentation, current procedural terminology, billing and disclosure of patient records? And will there be an increase of risk in the clinical setting to reduce the cost to Medicare, Medicaid or commercial carriers? The simple answer to the second question is no, there should be no increase of risk, with the caveat that you must strictly adhere to the rules of clinical decision-making, documentation, health-record dissemination, CPT code usage and billing practices.
Most healthcare providers strive to work ethically, give high-quality patient care and submit accurate claims for payment. Take note of the word “accurate” and its meaning: free from error, precise, meticulous, faithfully representing or describing the truth. Accuracy includes using E&M codes and CMT codes appropriately, truly understanding the definition of medical necessity and routinely billing E&M codes with a CMT for each DOS. Moreover, consider whether or not you have reduced the actual face-to-face time for an E&M with a Medicare patient because Medicare does not cover this service. Ask yourself if you only document PART within the initial exam as opposed to the required elements for a new patient E&M. And consider whether or not you charge patients over and above the normal and customary fees for an in-network provider service until they meet their deductible. Finally, ask yourself the following questions: Do you have a lower cash fee verses an insurance fee for the same service? Are you upcoding to meet your overhead needs? Have you waived deductibles or adopted a NOPE standard in your office?
The five most important laws that apply to all doctors are the False Claims Act (FCA), the Anti-Kickback Statute, the Stark Law (physician self-referral law), the Social Security Act and the U.S. Criminal Code. As stated in the Social Security Act, Section 1862 (a)(1)(A): "No payment will be made...for items or services...not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member." Medically necessary care is when the patient has a health problem or condition necessitating treatment, and the services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with treatment.
The changing healthcare laws will impact none of the above requirements, criteria, definitions or elements. However, the Department of Health and Human Services moved forward on January 17, 2013, and increased the privacy, security and protections for patient health records under HIPPA: “The final omnibus rule greatly enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law.” (HHS.gov NEWS RELEASE January 17th, 2013) This enhancement impacts your office procedures regarding compliance with HIPPA and the HITECH Act. Risks associated with the changing healthcare laws must be addressed in the following areas: When to bill and when not to, and what entities can have access to patient health records and when and why they cannot. It is time for a new document in your standard patient record format: A “Restriction on Uses and Disclosure” form.
Most healthcare facilities utilize initial intake forms, including a signed statement that allows the healthcare entity to seek payment from an outside payer. However, under the expanded regulation, patients have the right to choose to pay all fees out of their own pocket and by their signature restrict disclosure of their health information. This right holds true for a patient with in-network benefits. In the event your staff is not clearly educated on the impact of this restriction, take note that a generated and submitted bill to an outside payer constitutes unauthorized disclosure of a patient’s health information. The contract you sign as an in-network provider is mute against this federal law. Patients who choose to pay full price (as opposed to normal and customary in-network fees) and sign a restricted disclosure of their health information effectively stop the billing process to an outside agency.
Furthermore, with the implementation of ICD-10, there will be significant changes to the way you document. ICD-10 allows and results in a greater tracking of services, and accuracy will be essential in documentation and billing. According to the Centers for Disease Control and Prevention, “Whereas ICD-9 employs three- to five-digit codes, ICD-10 codes use three to seven digits.” (ICD-10-CM Official Guidelines for Coding and Reporting 2012).
It is a dynamic time to be in the healthcare industry. Accurate and complete patient records and documentation of all services and consents is an essential component to minimize clinical risk. Knowledge combined with management of changed healthcare laws for HIPPA and the HITECH ACT will be imperative for complete compliance in a clinical setting. Accusations of non-compliance of HIPPA or the HITECH Act as well as accusations of improper, unskilled, or negligent treatment of a patient can be clearly defended with precise and meticulous documentation. It is important to keep in the forefront of your mind that if you did not document it, it is the same as if you did not do it.
Healthcare laws will continue to expand both at the federal and state levels. Legal defense for malpractice as well as board and audit defense have become a growing concern for many chiropractors. Establishing and following a compliance program will help avoid errors and ensure that you are submitting true and accurate documentation and billing. If you are considering a particular billing practice or business-operating procedure, consult ChiroSecure. ChiroSecure is committed to providing the exceptional, quality protection you need by offering the most comprehensive coverage available at the most competitive rates. ChiroSecure will assist you with your compliance goals by providing education and risk-management tools to support healthcare industry demands. It takes an educated and compassionate team to support the goals of a compliant chiropractic office. Count ChiroSecure as one of the most active and supportive members of your team.
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