Is Medicare Knocking on Your Door?
ICS members continue to notify us about letters they are receiving from CMS stating that they are to “voluntarily” complete a self-audit for the accurate billing of Chiropractic Services with the AT modifier. Take heed and understand the investment Medicare is making in the audit of practices throughout the United States.
As you know, CMS concluded the demonstration project for chiropractic on April 1, 2007. At the same time, the Regional Auditor Contractor (RAC) Demonstration project also concluded on April 1, 2007. CMS deemed the RAC a stellar success and will employ the use of an outside agency for auditing contractors.
Meanwhile, the ACA announced that it successfully lobbied Congress to repeal a portion of the proposed cutbacks in reimbursement by CMS. Although a portion of the cutback did become reality for the geographic location rate, the 5% cut was repealed. CMS has indicated that the 5% repeal will cost Medicare approximately $10 BILLION. As a result, CMS has made a considerable investment in resources to increase audits to make up for a portion of the deficit. Doctors are encouraged to pay close attention and understand the ramifications of this notice.
In October 2000, the Office of Inspector General (OIG) released the final guidelines for the Compliance Program for Individual and Small Group Physician Practices. The OIG believes healthcare providers should voluntarily develop policies and procedures to prevent the reporting of erroneous claims or any conduct or behavior that is considered unlawful or non-complaint with the laws, statutes and regulations applicable to the delivery of healthcare services.
The Department of Health and Human Services (HHS) reported $1.9 billion recovered from 1996 through 1999. Recoveries from fines, settlements and judgments totaled $1.2 billion in 2000, $1.7 billion in 2001, and $1.8 billion in 2002. The largest settlement reached thus far with a single provider was for $920 million in 2006. As of December 2006, 1,904 chiropractors were excluded from the Medicare program.
As of October 1, 2004, CMS required the use of the AT modifier if active/corrective treatment is being rendered. The AT modifier coveys a message to CMS that the provider attests the care rendered for that date of service is under an active therapeutic program and is medically necessary. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.
If the doctor uses the AT modifier when he/she should have known that the care is maintenance, then the doctor may be guilty of fraud. If found guilty of fraud, the doctor may be assessed civil money penalties of $10,000 per item and three times the amount claimed, as well as exclusion from Medicare.
Although voluntary, a formal written compliance program with all Federal and state laws, guidelines and statutes is strongly advised. The OIG states, “Compliance programs strengthen the efforts of Government and the private sector to prevent and reduce improper conduct. These programs can also further the mission of all physician practices to provide quality care to their patients.” Consultation with a healthcare attorney or a Certified Medical Compliance Specialist (MCS-P) is recommended. Members may contact the ICS or me for further information.
If a comprehensive written compliance program is implemented, the reduction of errors should occur. If errors are uncovered in an audit, the doctor would have demonstrated that no knowingly and intentional errors were committed. Therefore, the OIG typically will demand a refund of amounts reimbursed in error, but typically no fines or jail time is imposed. Physicians are not subject to civil or criminal penalties for innocent errors.
If you discover an overpayment, take immediate action. Failing to disclose overpayments within 90 days of discovery can result in the government alleging a knowing and willful attempt at concealing overpayment. Complete the Overpayment Refund form each time a voluntary refund checks is sent to assure that the monies are credited timely and accurately. Be sure to complete the entire form.
Include the voluntary refund form with every refund. Be sure that you are returning the correct amount. Refer to the paid amount rather than the allowed amount when determining the overpayment. When you voluntarily participate in an OIG Self-Disclosure Protocol agreement, no appeal rights will be granted.
The Illinois Chiropractic Society continues to work diligently to bring information to the members of the ICS. Look for upcoming Medicare, OIG Compliance and Documentation classes sponsored by the ICS. In addition to classes, articles and ICS web site postings, the ICS now offers training CDs and DVDs for subjects such as HIPAA, Medicare, PI/Work Comp and Documentation. All CDs and DVDs are eligible for Category One CME.
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by Mario Fucinari, D.C., C.C.S.P, MCS-P