Medicare and Insurance Hot Topics of 2007
When it comes to Medicare and Insurance, there is no lack of hot topics. Here are a few to recap what have been the big issues so far in 2007.
Compliance
The Office of Inspector General (OIG) has come down hard on chiropractors. Following the June 2005 OIG report that stated that 67% of chiropractors’ claims were fraudulent, the OIG, Medicare and many insurance companies have been actively pursuing chiropractors. A compliance manual and active OIG compliance program has been explained in previous issue of this journal and in detail in publications sent directly to ICS members. Our Federal and state government, through refund demands and fines, have recouped millions of dollars. In the last week alone, two ICS members, who have been hit by demands of $300,000 by Blue Cross and $151,000 by Aetna, have contacted me. Who is next?
Medicare and the -AT modifier. Medicare has made two important changes in the last year. First, they have removed all screening parameters for reimbursement of chiropractic services. Secondly, they have begun to complete individualized analysis of chiropractic practices pertaining to the -AT modifier. In the former, this has resulted in many chiropractors being lulled into complacency because their claims are being reimbursed without question. However, if you find that you have been reimbursed for 50, 60, 70 or more visits in a year, this should throw up a red flag so prominent that it can be seen on a foggy night from 20 miles away! Why would Medicare ever pay for 60+ visits in a year? In my opinion, you are being set up for a fall.
Secondly, if you received a letter of analysis of your office, it should indicate to you that Medicare has you on their radar. If you have received this letter pertaining to your number of –AT modifiers used, you are being informed that your office procedures fall outside of the norm, compared to offices of your peers. As such, CMS is suggesting that you do a self-audit or have some one qualified do the audit for you, to see if you have erroneously billed for services that were not medically necessary. If you have billed for medically unnecessary services, it is suggested that you repay the money back voluntarily, before you are officially audited. If you feel your office may be vulnerable, you may wish to take a proactive approach to this problem and have an audit done. Please take this warning and suggestion seriously. One recent audit that I did for a doctor of their documentation and billing practices resulted in a repayment to Medicare of over $45,000.
Re-Examinations
The standard of care is that a re-examination is done “to determine progress and need for further care.” (Mercy Conference Guidelines) A re-examination should be done every 10-12 visits or 30 days in active cases. If a re-examination is not conducted in a timely manner, medical necessity has not been established. Following a re-examination, it is expected that a note or report be generated that outlines your assessment of the case, with an update of the treatment plan and treatment goals. If an examination is not done in a timely manner and a change in treatment plan and goals are not generated then this may result in a post-payment demand of refund of claim reimbursements.
P.A.R.T. This continues to be an area of great concern and interest for Medicare. In order to justify manipulation for a subluxation, you must first establish a subluxation is present in every region charged, for each visit. Furthermore, a diagnosis has to be generated for each region involved in your manipulation charge. In other words, if you are charging a 98941 CPT code on a patient to Medicare, you must document P.A.R.T. and generate a diagnosis for 3 - 4 regions. Anything less may result in a partial repayment of reimbursement funds.
Gifts and Inducements
In October 2000, CMS release a clarification on the gifts and inducements portion of the Stark Law. As such, it has been stated that it is illegal to waive deductibles and co-payments, and to perform services for no charge or for other than fair market value. If you are taking x-rays, performing examinations or physiotherapy on Medicare, Medicaid or Champus patients for free or other than fair market value, you are in violation of the Gift and Inducement portion of the Stark Law. If uncovered, you may face fines of up to $10,000 fines plus three times the amount at issue for each occurrence. If you are not actively collecting the patient’s portion of the fees, then this can be construed as participating in a No Out Of Pocket Scheme (N.O.O.P.E.). N.O.O.P.E. may result in fines federally and statewide as well as a loss of your license.
Advertising
Your advertising also falls under the gifts and inducement portion of the Stark Law. You cannot advertising for free services, or for amounts other than free market value, for services to your Medicare, Medicaid or Champus patients. Any such advertising must carry with it a disclaimer that excludes these groups of people. Even if you do not accept Medicaid or Medicare, if this group of patients enters your office and demands the service for free or a reduced payment amount, it may result in fines.
The State of Illinois and Advertising. The State of Illinois is taking a closer look of outside office signs, newspaper advertisements and yellow page advertisements. They want to be sure that the chiropractor specifically indicates that they are a doctor of chiropractic in their advertisement. This has been described by state auditors as having to say D.C. after the name, or Doctor of Chiropractic. Violation may result in fines.
Dr. Fucinari is a Certified Insurance Consultant and a Certified Medical Compliance Specialist (MCS-P). He also serves as the ICS President and Chairman of the ICS Medicare committee. He frequently assists doctors in audits of their practice for vulnerabilities in documentation, coding and compliance. For further information on the topics discussed above or for information pertaining to an audit of your practice by Dr. Fucinari, you may call him at 217-877-2404 or e-mail him at DOC@AskMario.com |
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Medicare and Insurance Hot Topics of 2007
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