What Do Insurance Companies Really Want From Me?
Practice Management
Written by Kathy Mills Chang, MCS-P   
Wednesday, 26 October 2011 20:40 Read : 344 times

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o you ever sit at your desk, look around at the stacks of requests, letters, and charts and ask yourself, “What do insurance companies really want from me, anyway?”  The volume of new regulations and rules are raining down at a fast and furious pace, and may feel like an out of control, runaway train.  We just master one new policy and they change the rules.  Keeping up with the modifications can make our heads spin, but it is vitally important to stay on top of everything. Usually, staying connected to your State and National Association, a trusted advisor, or consultant can keep you in the loop and up-to-date on regulatory changes. But what about the day-to-day inner workings of your practice?  With all that you manage, what are the handful of most important things to keep track of to steer your practice out of the danger zone, and operating on all cylinders?  Make sure that among all the stacks, rules, regulations, and forms to fill out, you master these five basics to keep your show on the road to success.
 
Understand Their Definition of Medical Necessity
There is a clear difference between most chiropractors’ definitions of what is clinically appropriate and what a carrier may define as medically necessary. When you are a third party to the relationship between your patient and their contracted insurance carrier, it’s important that you follow their rules. If you happen to be a contracted provider in their network, then you have your own rules to follow as well.  It’s my opinion that if you try to find out medical necessity definitions from the carriers you deal with, you will be well on your way to better documentation and an unmistakable showing of an effort toward compliance. 
 
Remember that medically necessary care is that which the carrier can justify as payable through the insurance. It is usually tied to certain diagnosis codes and based on medical review policy. They will not dictate what you recommend to a patient as needed treatment, but will dictate that portion which they will pay for. You can treat as you wish, but be sure you only submit for reimbursement that segment that your documentation shows will align with the medical review policy for that diagnosis. The remainder is the part the carrier expects the patient to pay. And the doctor is the link between the two. It’s based on your interpretation of the review policy, and your documentation of medical necessity is the lynchpin. 
 
Medical review policy is usually found on a carrier’s website, in the physician area, sometimes requiring a password. You can search using their search tools, or navigate to the appropriate section and use key words such as “chiropractic” or a specific CPT code like 98940. For example, many carriers will pay for orthotics. They will tell you upon verification that they are a covered service. But if you failed to read the medical review policy for orthotics, you may have missed the fact that orthotics are only covered if the diagnosis is “Diabetes”.  If you didn’t know that, you may be frustrated when your bill is denied for your diagnosis of “Plantar Fasciitis”.  
 
Be Proactive with Compliance
In 2000, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) encouraged the voluntary implementation of compliance programs in healthcare offices, particularly those that served the Medicare or Medicaid beneficiaries. In March 2010, as part of the Patient Protection and Affordable Care Act (PPACA), also known as “ObamaCare”, these compliance programs were made mandatory. While there has been no specific deadline by when they must be implemented, it’s likely going to be very soon. The majority of chiropractic offices do not have a compliance program in place. Those that do likely have a program that they bought years ago, thinking it made them compliant, and it has an inch of dust on it from sitting on the shelf. 

But if you failed to read the medical review policy for orthotics, you may have missed the fact that orthotics are only covered if the diagnosis is “Diabetes”.

 
Think of a compliance program as a self-policing program, where you proactively state that “this is how we do it here” and then keep to it. A Code of Conduct for your office sets the tone of compliance for your team as well. It involves voluntarily auditing yourself for coding, documentation and billing errors, and reporting them and paying back overpayments if necessary.  When these standards are stated, implemented, and managed, a third party looking in from the outside can see that you are not part of the problem, but part of the solution. A well organized office with a compliance program is less prone to simple mistakes.  And if they make errors, they catch them early, and deal with the fall out quickly. An office writing in to a carrier with an overpayment caught by the self-auditing process will be set apart as a stunning example of the way it should be. And you can imagine that if an error was found on a carrier’s audit, the fact that you routinely self-police is a strong, mitigating factor in your favor, trumpeting that you are not doing something fraudulent, which implies intent. 
 
A doctor I work with called recently with what they thought was the end of practice as they knew it….a team member had been falsifying billing for quite some time, and then stealing the extra money that came in. The numbers were staggering once we started digging and auditing. The amount that would need to be repaid was more than they could fathom. Some of it was from Medicare, which layered on another series of deadlines and regulations. But trust me when I say that this doctor coming forward to the several carriers involved, showing that “we found this as we audited” was a huge mitigating factor in their favor when the carrier began extending payment plans and other considerations. Just think of what would have happened if a carrier began an audit for another reason and found it before the doctor did. Setting up a compliance program is a simple process with an uncomplicated structure. Don’t be caught without one. 
 
Code and Bill Correctly
If you have a compliance program in place, then you probably will do your coding and billing appropriately.  The CPT and ICD numbers reported on your patient’s billing is the language used to communicate your services to the third party payer. Simple auditing techniques will make sure that errors are minimized. But, if you use codes that are not a clear and obvious description of the work you’re doing, you could run into trouble. Make sure that you clearly understand the parameters for the use of every code you bill. Some codes require particular modifiers, and others require certain pieces of documentation to be present in your notes for use of the code. When you report a code, and it’s paid, don’t assume that because they paid it all is well. Usually, errors are found on post payment audit, and “I didn’t know” is not an excuse that will hold water. Repayments of erroneously billed codes still have to be refunded. The great news is that coding and billing correctly in chiropractic is pretty easy.  Diagnosis codes are straightforward, and there are a small handful of CPT codes that apply to our services. Even with the implementation of ICD-10 in 2013, it’s an area of your practice that must be exactly correct. You can’t afford to take the risk of erroneous coding and billing. It will cost you time and money when you may have precious little of both.
 
Be Aware of Documentation Requirements
Federal and state reports on the audit of chiropractic documentation indicate that chiropractors don’t have a good handle on proper case management and documentation requirements. Some jump to purchase EMR software thinking it will solve all documentation problems, but end up with an unhappy experience. You must learn the requirements on your own and master the documentation of your care.  The best way to do this if you find your documentation lacking is to use a good paperwork system that will prompt you along the way with appropriate requirements so you don’t miss a thing. It’s a great bridge from the travel card you may be using now to EMR software that may be required in the future. Using appropriate forms will guide you and teach you the nuances of documentation that you must learn. The Medicare documentation requirements are easily found in your Medicare carrier’s Local Coverage Document (LCD). Read it! And implement those requirements. 
 
Don’t Charge the Carrier Significantly More Than You Charge Your Patient
Offices that routinely offer cash discounts to patients under the guise of “time of service” pricing are usually in violation of a myriad of inducement and compliance rules. It usually goes like this:  An insured patient’s carrier gets a bill for a manipulation, traction, and exercise at the doctor’s actual fee schedule, which comes to $120.  Meanwhile, a patient who has no insurance comes in and is quoted the “time of service” fee of $40.  Can you see why a carrier may have a beef with being “overcharged”? It’s a violation pure and simple, unless you’re following the OIG’s guidance of no more than a 5-15% prompt payment discount. Would an average of $12 savings (10% of the $120 actual fee) really help that cash patient? This is why most doctors are discounting far more than the allowed 5-15%. The easiest fix is to join a reputable Discount Medical Plan Organization (DMPO) like ChiroHealthUSA. This allows you to set a network fee schedule for your cash paying patients too, and this keeps insurers from feeling like you’re gouging just because someone has third party coverage. 
 
Focus on these five areas should strengthen your relationships with the third party payers you deal with. It’s important to keep them healthy and strong, so you can continue helping your patients be the best they can be, without worries of third party payer interference.  It’s possible! And it starts with you!

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and, since 1983, has been providing chiropractors with hands-on training, advice and tools to improve the financial performance of their practices. A well-known and sought-after speaker, Kathy has served in national and state level chiropractic organizations, sits on diverse boards and advisory councils related to the profession, and is frequently invited to address chiropractors in important conferences and seminars around the country. In 2007, KMC University was created to streamline, develop and offer a broader range of chiropractic solutions in the areas of coding, insurance, patient financial procedures, Medicare and compliance. She can be reached at 888-659-8777 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it

 
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