Yes, I know. Sounds strange doesn’t it?
trange as it sounds, it is far too familiar to those of us who work with doctors on a daily basis to help improve their documentation, billing, coding and collections. We see examples of doing the right thing the wrong way every day in chiropractic clinics across the nation. It happens when doctors attempt to do the right thing in helping patients with no insurance or limited benefits by “tweaking” their documentation and coding to result in an overall lesser charge for the patient.
Be honest. Have you ever had a patient that required more than a routine workup but you used a lower level exam code because you knew they had no insurance coverage? Perhaps a 99202 instead of a 99203? No big deal right?
Or, as long as we are being honest, have you had a patient that you adjusted full spine, 4-5 levels, and you only charged a 98940 for 1-2 levels? No big deal right?
Ok, let’s try one more. How about this scenario? Have you ever had a Medicare patient that required a detailed workup and x-rays and you charged a lower level exam code or just billed for 2 x-rays when you actually performed 4, because you know Medicare doesn’t cover your exams or x-rays? No big deal right?
All of these are examples of down coding your services in an attempt to strike a balance between what insurance coverage may allow and what you feel your cash or underinsured patients can afford.
We all know if you don’t perform a service you should not bill for it…it is called fraud. However, few may be aware that if you DON’T report what you did and DON’T charge for services you would normally bill to insurance because you are seeing a cash patient there is also the potential for fraud because of a dual standard of care and a potential dual fee schedule.
Not to mention, down coding or failure to bill Medicare patients can be considered an inducement and subject to serious fines and penalties according to the Office of Inspector General and CMS.
The bottom line is that down coding can be perceived as illegal and inappropriate just as up coding is when it is used to allow you to bill differently based on whether the patient is insured or a cash patient. It is “gaming” the system pure and simple. It is doing the right thing to help the patient, but it is being done the wrong way and it can cost you.
What drives doctors to down coding or not charging for all their services? It’s really quite simple. There is the need to maximize reimbursements by billing your UCR fees or contract rates to insurance companies, but you haven’t found a good way to make care as affordable as you would like for your cash and underinsured patients.
So the only tool you have is to “tweak” the documentation, coding or billing to allow you to do what you would like to do. It really is that simple, but it can REALLY be very costly if you are audited!
It really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees.
So how can you document as you should, bill as you should and code properly for maximum reimbursement when there is insurance available and still be able to help the cash patients? You MUST join and encourage your patients to join a cash discount program, commonly known as Discount Medical Plan Organizations or DMPOs.
It really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees. It allows you do what you are attempting to do now…help the cash or underinsured patients. But, with a network contract, you can do it without “tweaking” your documentation, coding and billing and you avoid running afoul of dual fee schedules or illegal inducements.
So, do the right thing! Document correctly. Code correctly. Bill correctly. And, consider joining one of the cash discount plans which allow you to “contract” with cash and underinsured patients so you can discount correctly.
The contract model is not new. The contract model is what allows you to contract with multiple insurance companies for different rates for the same codes without it being considered a “dual fee schedule”.
Cash discount plans simply provide you the protection of a “contract” and allow you to document, code and bill properly and still pass on some savings to your cash and underinsured patients.
If you are documenting properly, coding properly and billing properly, good for you! Just make sure you don’t do the right thing the wrong way by trying to use a “bookkeeping reduction” or Time of Service discount that can be open to interpretation as to what is a “reasonable” discount. Far too many clinics use these tactics or strategies improperly in trying to help cash and underinsured patients.
Most all patients are familiar with “buying clubs” like Sam’s Club and networks and they don’t hesitate to join these plans to save money! A good cash discount plan solves so many of the potential problems for you as a provider when it comes to avoiding dual fees and creating inducements. And, they really help the patient…the RIGHT WAY!
THE MAIN THING IS....THERE IS NO WRONG TIME TO DO THE RIGHT THING!
If you’re offering discounts and you are not sure you are following state AND federal rules and regulations, doing NOTHING is NOT an option! There is NO good reason to put off solving this problem when it can be fixed so easily! Take action and start looking at the cash discount plans that are available and use the one that best suits your practice.
Article submitted by ChiroHealthUSA
Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He is a former President of the Mississippi Chiropractic Association and served 12 years on the Mississippi State Board of Health. He is a Fellow of the International College of Chiropractic, as well as member of the ACA. You can contact Dr. Foxworth at 1-888-719-9990 or