9/20/2020 1 Clean Up Your Chiropractic Front Of House Fall Convention Wisconsin Dells September 25,2020 We assume no liability for data contained or not contained in this presentation and assume no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this seminar. CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly assume any liability for data contained or not contained in this seminar workbook. This seminar workbook provides information in regard to the subject matter covered. Every attempt has been made to make certain that the information in this seminar workbook is 100% accurate, however it is not guaranteed. Disclaimer: The views and opinions expressed in this presentation are solely those of the author We do not set practice standards. We offer this only to educate and inform. 1 2
Transcript
9/20/2020
1
Clean Up Your Chiropractic
Front Of House Fall Convention Wisconsin Dells
September 25,2020
We assume no liability for data contained or not contained in this presentation and assume
no responsibility for the consequences attributable to or related to any use or interpretation
of any information or views contained in or not contained in this seminar.
CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly
assume any liability for data contained or not contained in this seminar workbook. This
seminar workbook provides information in regard to the subject matter covered. Every
attempt has been made to make certain that the information in this seminar workbook is
100% accurate, however it is not guaranteed.
Disclaimer: The views and opinions expressed in this
presentation are solely those of the author
We do not set practice standards. We offer this only to
educate and inform.
1
2
9/20/2020
2
Maya Angelou – American Poet
If you are always trying to be normal, you will never know how
AMAZINGyou can be.
3
4
9/20/2020
3
Christopher R. Anderson DC, MCS-PClinic Director
www.AskDrAnderson.com
www.AndersonClinics.com
5
6
9/20/2020
4
We have many past
on demand webinars
at wichiro.org under
the Help Desk tab.
*You must be signed
in with your WCA User
Name & Password to
access.*
7
8
9/20/2020
5
Have a Question?
Call us at the WCA Help Desk
9
10
9/20/2020
6
11
12
9/20/2020
7
• Chiropractic practices are team player environments.
• If you can’t get along with others, a chiropractic office is not the place to work. • Remember, if you are a people person, working with other teammates becomes
an easy task.
A Tour of An Compliant Clinic
13
14
9/20/2020
8
Displaying NameProfessional title.
• A licensee shall use the suffix “D.C." or “Chiropractor" immediately following his or her surname for proper identification. The title “Doctor" or “Dr." may be used if “Chiropractor" is used following the name.
Websites, Posters, signs, etc..
Display of licenses
• The license shall be displayed in a prominent place by every person licensed and currently registered by the board.
15
16
9/20/2020
9
Waiting Room• Child Safety?
• HIPAA Notice of Privacy Practices (Posted and on
Website)• Manual in Clinic
• Privacy Officer, Security Officer and Compliance Officer?
Pictures of Patients in Clinic
• HIPAA Approval from parent within the last year for each of these picture. (Obtained yearly)
• Includes website• Staff Families• Do you have a signed Minor Release Form
Signed Every Year?• Legal Guardian/Parent• Need all staff to Treat the Child, and
employees
17
18
9/20/2020
10
Entering the Clinic/Front DeskChecking IN
Can Anyone Hear what you're talking about?
Private Conversations?
Screen Protectors?
Screen Saver on Auto Check-in
! ! ! ! HUGE ! ! ! !
• HIPAA compliance standards protecting confidential health information were enacted. The patient privacy rules set standards to protect the privacy of patient personal health and billing information.
• The provisions of the law mandated stringent standards for patient privacy protection, requiring businesses and practitioners to protect the privacy and security of medical information both in electronic and printed formats.
• Full HIPAA compliance has been required by federal law since April 14, 2003. • The rule is enforced by the HHS Office for Civil Rights (OCR), and OCR was named
responsible for providing assistance to health care providers, hospitals, insurance agencies, doctor offices and health clearinghouses in meeting the regulation's requirements.
19
20
9/20/2020
11
Benefits Consultation Room
Get an ID…Protected under HIPAA
• Verify Identity and Insurance Coverage • Scan it in system
• If refuse must visualize it at least.
21
22
9/20/2020
12
Picture ID Policy
23
24
9/20/2020
13
25
26
9/20/2020
14
Does your Clinic Use…
• Email communications containing protected health information (PHI) need to meet certain HIPAA security standards to satisfy compliance guidelines. These standards are left purposely flexible, which in turn can lead many businesses to wonder whether they’re transmitting PHI according to HIPAA’s Security and Privacy rules. The “reasonable safeguards” for email include precautions like encrypting patient-bound email and verifying recipients’ identities prior to disclosing personal information.
• While HIPAA email rules don’t directly require encryption at all times (inter-agency emails, for instance, don’t have mandatory encryption rules), encrypted email by nature fulfills all requirements of HIPAA: sender and recipient are both verified, PHI is protected coming and going and the extra effort taken by all parties involved constitutes a reasonable safeguard.
• What happens if a covered entity — that is, a healthcare provider, health plan or healthcare clearinghouse – uses Gmail, but neglects HIPAA compliance? Penalties can add up quickly because they are “per violation,” which means every single email that violates HIPAA requirement constitutes a fineable event. Penalties are broken down into four tiers:
• Did not know: Some organizations may honestly be unaware that their email communications are non-compliant. This tier carries a $100 to $50,000 penalty per incident (again, that is per individual email).
• Reasonable cause: Penalties range from $1,000 to $50,000 for organizations that know email needs to be compliant, but aren’t making an effort in that direction.
• Willful neglect (corrected): If you have access to HIPAA compliant Gmail or another compliant email server and still don’t follow the requirements for compliance, penalties between $10,000 and $50,000 can be issued.
• Willful neglect (not corrected): A flat $50,000 penalty can be imposed upon users who have already been warned about being in non-compliance, yet have made no effort to change policies or actions.
• The maximum annual fine is $1.5 million for each covered entity.
• However, Google can support HIPAA compliance for those Google App customers who are willing to sign a HIPAA Business Associate Agreement (BAA) with Google.
• The BAA ensures certain measures to protect data stored on Google’s servers, but it does not come with email encryption built in.
G Suite for Business Users
• Fortunately, Google offers additional services to businesses. GSuite is a collection of the most-used Google apps for business, including Gmail, Google Drive, and Google Calendar, specially packaged for enterprises. GSuite must be associated with a domain that the user owns and is a paid service.
• Although GSuite gives users access to Gmail, the most significant difference lies in Google’s ability to sign a BAA. This means that healthcare providers who wish to use Gmail as an email service for their company have the opportunity to purchase GSuite, link it to their company’s domain, and handle the technology component of the solution triad.
• But not so fast: this does not create a HIPAA compliant solution. There’s more to do after a BAA is signed to ensure that all patient data that would be shared over email is protected. Encryption is a critical component of verifying that patient information is safe when being transmitted via email.
• Validate that you are only communicating with the intended party. This falls under the Privacy Component. By using PKI infrastructure and the encryption of the email using the patients Public Key, you can increase the level of confidence in the “privacy” of this communication.
• Confirm that the transmission cannot be intercepted. This component falls under Confidentiality. This is where encryption plays a role. As the communication is encrypted via the patients Public Key, only the patient can decode the message using their Private Key.
Communication Documentation
31
32
9/20/2020
17
Training your Staff
• 1 Hour of HIPAA • 1 Hour Compliance/OSHA
• (Wet and not yours don’t touch it, gloves, tongs to pick up glass)
• 1 Hour Emergency Procedures
Break Room• Need to Separate Samples in Separate
Fridge than Food. (Functional Chiropractic Medicine)
• It’s the Law Posters (OSHA. Gov or…)
33
34
9/20/2020
18
State and federal employment laws/regulations require all employers with at least one employee to post at each of their locations, in an area frequented by all employees, all applicable, current, required federal and state employment law notices
35
36
9/20/2020
19
https://dwd.wisconsin.gov/dwd/posters.htm
Federal Government Workplace Posters
37
38
9/20/2020
20
Occupational Injuries and Illnesses Summary
All employers covered by Occupational
Safety and Health Act of 1970, and all public
employers covered under COMM 32
Penalty for Violation
citation issued
39
40
9/20/2020
21
• Non-Mandatory Appendix A to Subpart B -- Partially Exempt Industries• Starting on January 1, 2018, the following NAICS will be partially exempt
from OSHA recordkeeping requirements:• Non-Mandatory Appendix A to Subpart B -- Partially Exempt Industries• Employers are not required to keep OSHA injury and illness records for any
establishment classified in the following North American Industry Classification System (NAICS), unless they are asked in writing to do so by OSHA, the Bureau of Labor Statistics (BLS), or a state agency operating under the authority of OSHA or the BLS. All employers, including those partially exempted by reason of company size or industry classification, must report to OSHA any workplace incident that results in a fatality, in-patient hospitalization, amputation, or loss of an eye (see §1904.39).
6213 Offices of Other Health
Practitioners
• Like in other areas of compliance, OSHA investigates incidents of non-compliance and assesses financial penalties to employers where health and safety requirements were not implemented and met.
• As OSHA's primary initiative is to minimize the risk of injury and illness in the workplace, the organization is very proactive with enforcement efforts.
• It is the responsibility of the employer and delegated workforce to define, implement, and train according to the OSHA guidelines and specific health and safety policies and procedures of the practice.
• The entire practice workforce is responsible for following these policies and procedures as protective measures for all.
• OSHA is so important that general safety-related training and role-based safety training is required immediately on hire and refreshed at least once per year thereafter.
• If your practice hasn’t implemented the required elements of OSHA compliance, be sure to set a goal to do so in the coming months.
OSHA• Occupational Safety and Health Administration (OSHA) governs workplace
safety• Many states have their own version that may have stricter rules and/or
resources• They will do a free onsite audit to help you get to legal
43
44
9/20/2020
23
The On-Site Consultants Will
• Help you recognize hazards in your workplace.
• Suggest general approaches or options for solving a
safety or health problem.
• Identify kinds of help available if you need further
assistance.
• Provide you a written report summarizing findings.
• Assist you to develop or maintain an effective safety
and health programs.
• Provide training and education for you and your
employees.
The On-Site Consultants Will Not
• Issue citations or propose penalties for violations of
OSHA standards.
• Report possible violations to OSHA enforcement
staff.
• Guarantee that your workplace will "pass" an OSHA
inspection.
OSHA Compliance in Healthcare
• The Occupational Safety and Health Administration (OSHA) is an organization established by the United States Department of Labor. The goal of OSHA is to help ensure the health and safety of workforce members for most industries (including healthcare).
• OSHA is an essential component of compliance that must be properly implemented in the form of documented policies, procedures, and appropriate employee training. Chiropractic offices usually present a very low risk in the grand scheme of OSHA.
• Some chiropractic or multi-disciplinary practices draw blood for lab work, oroffer acupuncture (which requires a sharps kit for needles), while others may conduct Department of Transportation (DOT) physicals and collect urine samples; but most chiropractic offices must simply comply with the most basic and general tenants of OHSA compliance.
• These are the required guidelines that minimize the risk of incident, injury, or illness for healthcare workers.
45
46
9/20/2020
24
These include, but are not limited to the following standards that should be scaled and personalized to the practice:
Emergency Action Plan
• Have a documented protocol for emergency management, evacuation, and reporting in the event of an emergency (e.g., such as severe weather)
• Identification of OPIM (Other Potentially Infectious Materials) that you may encounter in your office (e.g., vomit, blood, or even a baby diaper that leaked).
• Procedures should include how to properly sanitize, minimize exposure, manage needles and sharps, and meet reporting guidelines for OPIM-related incidents and unsafe exposure
Blood Born Pathogens
• OSHA has direct minimum guidelines• Your policy should address:
• Handling blood or other body fluid spills
• Patient treatment with open wounds or lacerations
• Hepatitis B vaccinations and/or declination of employees who might come in contact with body fluids (even if your doctor is anti-vaccine)
• How the office will handle the event of a needle stick and/or coming in contact with body fluids for patients and/or team members
51
52
9/20/2020
27
Personal Protective Equipment (PPE)
• Have access to personal protective equipment (e.g., gloves, masks, and other items) to minimize employee exposure to OPIM or other items or materials that may pose a risk to health and safety of the person responsible for cleaning up a spill or incident
• If it is wet and not yours, DON’T TOUCH IT
53
54
9/20/2020
28
Management of Sharps• How should sharps containers be handled?
Each sharps container must either be labeled with the universal biohazard symbol and the word "biohazard" or be color-coded red. Sharps containers must be maintained upright throughout use, replaced routinely, and not be allowed to overfill. Also, the containers must be:
• Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping;
• Placed in a secondary container if leakage is possible. The second container must be:• Closable;• Constructed to contain all contents and prevent leakage during handling, storage, transport,
or shipping; and• Labeled or color-coded according to the standard.• Reusable containers must not be opened, emptied, or cleaned manually or in any other manner
that would expose employees to the risk of percutaneous injury. • Upon closure, duct tape may be used to secure the lid of a sharps container, as long as the tape
does not serve as the lid itself.
• Where should sharps containers be located?
Sharps containers must be easily accessible to employees and located as close as feasible to the immediate area where sharps are used (e.g., patient care areas).
• What type of container should be purchased to dispose of sharps?Sharps containers are made from a variety of products from cardboard to plastic. As long as they meet the definition of a sharps container (i.e., containers must be closable, puncture resistant, leak proof on sides and bottom, and labeled or color-coded), OSHA would consider them to be of an acceptable composition.
55
56
9/20/2020
29
How do I dispose of regulated waste?
• Disposal of all regulated waste must be in accordance with applicable state regulations. These rules are typically published by state environmental agencies and/or state departments of health (Go to HERC Regulated Medical Waste Locator ).
• In addition to state rules for disposing of regulated waste, there are basic OSHA requirements that protect workers. The OSHA rules state that regulated waste must be placed in containers which are:
• Closable;• Constructed to contain all contents and prevent leakage of fluids during handling,
storage, transport or shipping;• Labeled or color-coded in accordance with the standard; and• Closed prior to removal to prevent spillage or protrusion of contents during handling,
storage, transport, or shipping.• If outside contamination of the regulated waste container occurs, it must be placed in a
second container meeting the above standards.• OSHA has no specific requirement for hospitals or other healthcare facilities to treat
(e.g., autoclave) waste before disposal. Such rules are usually published by state agencies
What is your action plan?• Bloody nose all over Bathroom
What is your action plan?• Poop on Chiropractic Table
59
60
9/20/2020
31
What is your action plan?• Vomit on a Chair in waiting Room
Medical and First Aid
• Identifies the required first aid supplies necessary for entities to keep on hand and accessible to employees in the event of a work-related injury where basic first aid is necessary
61
62
9/20/2020
32
Items in Clinic First Aid Kit • small, medium and large sterile gauze dressings• at least 2 sterile eye dressings• triangular bandages• crêpe rolled bandages• safety pins• disposable sterile gloves• tweezers• scissors• alcohol-free cleansing wipes• sticky tape• cream or spray to relieve insect bites and stings• antiseptic cream• distilled water for cleaning wounds• eye wash and eye bath
Where is you First Aid Kit Located?
63
64
9/20/2020
33
CPR Masks in Every Room, or easy Access?
Key highlights:
• Practice your skills often• Get your staff certified• Purchase an AED for your office• Develop an in-office action plan
65
66
9/20/2020
34
HallwaysDo you know where the Clinics Fire Extinguishers Are?You have them Checked ? Emergency Lighting ?Exit Signs?
Digital Imaging
67
68
9/20/2020
35
Last Year
• We had an inspection!• Written Safety Policy• Employee Notice posted• ALARA• Personal Dosimetry• Personal Dosimetry Declared Pregnant worker• Technique Charts• Lead Gloves and Aprons• Imaging QC Digital• Gonad Shielding• Equipment warning label
Ionizing Radiation
• Facilities with an x-ray machine must implement protective gear and follow additional safety protocol to limit employee exposure to areas where radiation is present
• Sign about pregnancy• Non Pregnancy Verification Form
• Digital Imaging, Ultrasound, E-stim, act
69
70
9/20/2020
36
Chiropractic X-Ray Regulatory Guide
Chiropractic X-Ray Regulatory Guide
A Member Benefit
71
72
9/20/2020
37
How Should I Dispose of Old X-rays?• Law require adult patient X-rays be kept on file for seven years after the last date of
treatment. • It may not be acceptable to destroy films if you are keeping the other medical records.• Minor patient X-rays generally need to be retained until the patient reaches age 25.• After that timeframe, you can dispose of the films, as long as you do it properly from a
patient privacy perspective and in accordance with EPA regulations. Due to HIPAA privacy requirements, you cannot simply throw X-rays in the trash. Films must be destroyed. Some states even require the notification and response of patients before the destruction of records, including X-rays.
• In general, proper disposal methods include shredding, burning, pulping or pulverizing the records so that patient health information is rendered essentially unreadable and cannot be reconstructed. The challenge is that home and office shredders are not sturdy enough to destroy X-rays and the films have hazardous material that cannot be legally disposed of in landfills.
• If you enlist a company to destroy your X-rays, work through a professional document shredding company and make sure the company prepares a HIPAA Business Associate agreement and provides a certificate of destruction.
Acupuncture/Massage Room
• Audit: Clinic Manager Specified that they just throw them out• Sharps Container• Policy for Proper Draping, act• HIV? Hepatitis C? (1950-60 28% Positive for it) (Tattoos)
73
74
9/20/2020
38
Treatment Rooms
• Opening adjusting rooms, HIPAA mandate that patient informed but they can request treatment in private and have an alternate room to treat them.
• Documentation• If you did not record it, it did not
happen• HIPAA (Paperwork on desk)• PPE• CPR Mask
Documentation – Signatures
• Handwritten or electronic signature accepted• Must be signed prior to billing • Stamp signatures not acceptable
• Exception for physical disability • CR 8219 dated June 18, 2013
• Physicians can not add late signatures • Except short delay during transcription
75
76
9/20/2020
39
Use Signature Attestation
• No signature on progress/treatment note submitted – attestation sample • “I, (name of doctor)_______________, hereby attest that the medical records
entry for the date of service _________ , accurately reflects signature/notations that I made in my capacity as a D.C. when I treated/diagnosed ___________________________.”
• I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
• Signature: X _____________________ • Date Form Completed X _______________________
Therapies/Active Care • Some therapies have counterindications
which could harm the patient:• Pacemaker for EMS or ultrasound• Open wounds • Active Cancer• Heart conditions with rigorous exercises• Balance issues • Pregnancy• Current flu/cold • Medications (blood thinners and others)• If the patient has these or others, it does
not mean they cannot have the treatment. Alert your doctor and they will assess the risks of the therapy vs. the rewards of treatment
77
78
9/20/2020
40
• Healing begins with Attitude.
• Nothing exudes a great attitude of caring more than a genuine warm smile. • Smiling can even help to heal yourself and others. Smile often and watch
others smile back at you.
Tips for Success
• A great phone voice and presence is essential to being an excellent CA.
• Always answer the phone with a big smile. Believe it or not, the person on
the other end can “see” that big smile. • Next, listen carefully to what the person needs and repeat back for confirmation. • finally, be a great people person and take care of the caller’s needs as you would
want someone to take care of yours.
79
80
9/20/2020
41
Who Knows What They Have Been Told?
• Have they seen another DC? • Received Digital Imaging• Blood Work?• Did they do things correctly? • Do they understand what Medicare
covers for Chiropractic? • Are they “set” in their thinking?
Clinic Sunshine
• Send a card… it makes a difference!
81
82
9/20/2020
42
• Organization is the
hallmark of success. To be better organized, have your desk completely cleaned off every evening before you leave.
• That means you must complete all of the day’s work on that day. Don’t leave filing or insurance claims for the next day.
• Do everything the same day and watch how easy and effortless your job becomes.
83
84
9/20/2020
43
85
86
9/20/2020
44
Internal Financial Notes
• Find a place in your software where you can keep internal notes• What if you win the power ball?• Less is NOT more in this situation• “And then I said, and then he said, and then I said…”
OVERLOOKED CHIROPRACTIC ASSISTANT TIPS
• Train and never ever ever ever stop training!• I don’t care if somebody’s worked with you for 45 years! Training never
ends.• The second law of thermodynamics called Entropy states that organized
systems tend to go to their least organized state when left to their own accord.
• What do you train on?
87
88
9/20/2020
45
Front Desk Considerations
• Patient Payment Arrangement• Patient Election to Self Pay
89
90
9/20/2020
46
Front Desk Considerations
• Patient Payment Arrangement• Patient Revoke to Self Pay
Front Desk Considerations
• Magellan Waiver
91
92
9/20/2020
47
Front Desk Considerations
• Medicaid/Badger Care Patients Counter sheet
Front Desk Considerations• Hypertensive Blood Pressure Sheet
93
94
9/20/2020
48
Front Desk Considerations
• Authorization For Verbal Communication and/or To Leave Voice Mail Messages
Front Desk Considerations
• CONFIDENTIALITY AGREEMENT FOR WORKFORCE MEMBERS WHO ARE CONSULTANTS, CONTRACTORS OR VENDORS
95
96
9/20/2020
49
Front Desk Considerations
• 1500 Claim Form
• In Box 12, you will see the phrase “Signature on File.” This means that you have given us authorization to release medical information necessary to process your claim.
• In Box 13, you will see the phrase “Signature on File” which authorizes payment of medical benefits to your clinic. A blank box indicates that you have not given the clinic authorization to assign payment of medical benefits
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
97
98
9/20/2020
50
• Financial Policy
Sign and Date
Once a Year
99
100
9/20/2020
51
•In
form
ed C
on
sen
t to
Ch
iro
pra
ctic
Tre
atm
ent
Notice of Private Practices
101
102
9/20/2020
52
Please Consider
• Resigned 1 x a Year• 1st time in January
• Policies Should be reviewed Yearly Compliance Manual
• 1500• Notice of Private Practices • Financial Policy• Consent
103
104
9/20/2020
53
Outcome Assessment Tools
105
Using OATs
Patient
Provider
Payer
Public
“Outcomes in clinical
practice provide the
mechanism by which the
health care provider, the
patient, the public, and the
payer are able to assess
the end results of care and
its effect upon the health of
the patient and society.”
Outcome Assessment Tools
• Support medical necessity by quantifying patient functional loss.
• They “objectify the subjective” • They measure a change in health status after
exposure to a health care delivery system.
106
Goals
105
106
9/20/2020
54
Outcome Assessment ToolsNeck Disability Index (NDI)Modified Oswestry Low Back Disability Index
• Ten questions, six responses scored on an ascending scale (0, 1, 2, 3, 4, 5), total is divided by # of points possible
• Higher percentage = worse disability• Administer at intake and every 6-12 visits, or 2-4 weeks
107
Goals
NDI scoring• 0-4 points (0-8%) no disability• 5-14 points (10-28%) mild disability• 15-24 points (30-48% ) moderate disability• 25-34 points (50-64%) severe disability• 35-50 points (70-100%) complete disability
i.e. 34% on NDI could be documented as “moderate functional deficiency”
108
Goals
107
108
9/20/2020
55
Oswestry scoring
109
Goals
110
Goals
OATs should be administered every 30 days, or as
indicated
• 10% improvement = minimum detectable change
• 30% improvement = meaningful change
• 50% improvement = substantial change
109
110
9/20/2020
56
Outcome Assessment Tools
111
Goals
OATs Inspired Goals• Goals need to be measurable and specific• Change ADL by this much by this date
“Enable patient to lift heavy weights without pain by 5/1/2016.” - from NDI, section 3
“Improve ability to stand without pain from 30 minutes to one hour by 5/20/2016.”- from Oswestry, section 6
Anthem Denials Update• Anthem Bcbs is using company called cotiviti to implement correct coding guidelines – result is
increased claim denials.• Both cpt codes and dx codes are causing denials.• Cpt: some e/m codes are being bundled with adjustments, despite the use of -25 modifier on
e/m code. • Contact Provider Services to dispute the denial. If this does not change outcome, document the
call reference # and send appeal with medical records.• Dx: some dx codes cannot be used together, or are considered mutually exclusive per icd-10
coding guidelines. S-codes which are injury codes used in personal injury cases appear to be main culprit. Ex: S33.140D and M53.2X7.
• If you have any claim denials due to mutually exclusive diagnosis codes, the best fix would be to remove the code causing the error, replacing with another code that would be appropriate, and resubmit the claim.
and then scroll down to click on the orange subscribe button.
• The following link to the AIM Rehabilitation website also provides helpful resources on physical therapy clinical guidelines: www.aimproviders.com/rehabilitation – select Resources in the top left; the following page provides access to physical therapy checklist and guidelines.
• This policy change and pre-authorization requirement for therapy services is Anthem’s method of getting in front of the Medical Necessity process. Anthem needs to see Medical Necessity for these therapy services before it can pay on a claim and is trying to streamline the process. WCA has been in contact with Anthem BCBS and has researched this pre-authorization requirement from a policy as well as legal standpoint.
• If we had a recourse to challenge this policy change, we would be doing so, as it is ALWAYS our mission to advocate for WCA members and the great profession of chiropractic. Anthem has taken the necessary steps to institute and impose this change, and DCs as well as other health care providers that provide therapy services are required to follow policy. It is because of this that WCA partnered with Anthem BCBS and presented a complimentary Help Desk webinar on September 10, 2020, designed to educate and train member DCs on how to obtain the pre-authorization for therapy services.
• The notification date was 4/1/20 with the end date for the code pair made
retroactive to 1/1/20. In response to the deletion of this edit, Optum
will no longer issue denials, sourced to NCCI, when CPT code 97122
is billed with a CMT code.”
• The letter goes on to direct providers to submit a request for
reconsideration of the denied service through the insurance carried.
• A sample request for reconsideration letter can be found in the link below.
“We appreciate being able to collaboratively resolve this issue with West
Bend and Optum and assist our members in being paid properly for the
services they provide,” said John Murray, WCA Executive Director and
CEO.
• Date: • To: XYZ Insurance, Provider Relations • From: ABC Chiropractic Clinic • Re: Request reconsideration for improper denial of CPT 97112
• Good morning, Our clinic has received denials for claims in calendar year 2020 in which CPT 97112 [Neuromuscular Re-education] was provided on the same date of service with CPT codes 98940 through 98943 [Chiropractic Manipulative Treatment]. These denials are improper, as the National Correct Coding Institute removed the procedure to procedure edits for these codes effective January 1, 2020. [Add the following paragraph if submitting to West Bend Mutual, or any insurer for which Optum was involved in the denial: Please see the attached letter dated June 26, 2020 from Optum which explains the reversal of their policy. ] We therefore request reconsideration of, and reimbursement for, all denials for this code encountered in calendar year 2020. Please find attached EOB detail or other detailed documentation, with aggregate totals shown below: Number of instances of denied 97112: Fee for each instance of denied 97112: Total amount requested for reconsideration: $ We will anticipate your response within 30 days. Thank you in advance for your cooperation.
• Sincerely,
125
126
9/20/2020
64
Humana Denying Therapy Codes for Lack of Modifier
• A recent policy implemented by Humana requiring the -96 or -97 modifier on therapy codes has started to result in denials just this month. Here is what we know so far:
• The policy was effective 1/1/18 but Humana only recently began implementing it in early 2019
• The policy impacts Humana Individual policies and Small Group policies• The policy coincides with new modifiers created by the American Medical Association
effective 1/1/18 to distinguish between rehabilitative and habilitative services.
• Since a chiropractor most often will administer rehabilitative services, then the modifier 97 will be used for Humana Commercial plans. Modifier 96 and 97 should not be used together on the same claim.
• Humana plans in the individual and small group markets have separate limits on rehabilitative and habilitative services.
• For dates of service beginning on or after January 1, 2019, providers must append modifier 96 to procedure codes for habilitative services submitted for reimbursement & modifier 97 to procedure codes for rehabilitative services submitted for reimbursement. Claims submitted without these modifiers will be denied for lack of modifier.
• Denied claims should be appealed.
• These modifiers should only be used for Humana individual and small group policies. We are not advising that you append modifier -97 to therapy claims for other insurance companies at this time.
127
128
9/20/2020
65
Using Modifiers 96 and 97• The Affordable Care Act (ACA) requires coverage of certain essential health benefits
(EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. As of January 1, 2018, there are two informational modifiers which should be used when reporting these two different types of services. Since physical therapy services may be either habilitative or rehabilitative, the appropriate modifier needs to be used when reporting these services.
• What's the Difference?• Habilitative (modifier 96): services that help a person DEVELOP skills or functions they
didn't have before.• Rehabilitative (modifier 97) services that help a person RESTORE functions which have
become either impaired or lost.• Requirements may vary from payer to payer. Let's examine some key concepts
excerpted from one payer's policy (emphasis added):
• Rehabilitative• The therapy is aimed at improving, adapting or restoring functions which have been
impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality; and
• There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time
• Habilitative• The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs
which, as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality, either:• have not (but normally would have) developed; or• are at risk of being lost; and
• There is the expectation that the therapy will assist development of normal function or maintain a normal level of function;
• An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service.
• - Amerigroup Guideline #CG-REHAB-04
• Since a chiropractor most often will administer rehabilitative services, then the modifier 97 will be used for Humana Commercial plans. Modifier 96 and 97 should not be used together on the same claim.
• Humana plans in the individual and small group markets have separate limits on rehabilitative and habilitative services.
• For dates of service beginning on or after January 1, 2019, providers must append modifier 96 to procedure codes for habilitative services submitted for reimbursement & modifier 97 to procedure codes for rehabilitative services submitted for reimbursement. Claims submitted without these modifiers will be denied for lack of modifier.
Modifier 97 for rehabilitative services
131
132
9/20/2020
67
CBD Oil• The main reason why DCs cannot sell CBD oil is
because it’s not considered a nutritional supplement by the FDA, it is considered a drug. Drugs are not within scope for WI DCs. Other establishments that sell CBD oil are bound by different standards which may or may not allow them to sell CBD oil, and that is a risk they take. For example, health stores which sell CBD oil may be able to ring up the transaction, but the store clerk cannot counsel or advise on CBD oil or risk the unlawful practice of medicine which could get them into trouble. Since this is an evolving topic, we are continuing to monitor the situation and will provide updates as anything changes.
Recognizing Child Abuse and Neglect: Signs and Symptoms
• DCs are mandatory reporters of abuse for minors. For adults, WI law specifies limited required reporting.
133
134
9/20/2020
68
Recognizing Child Abuse• The following signs may signal the presence of child abuse or neglect.
• The Child: • Shows sudden changes in behavior or school performance• Has not received help for physical or medical problems brought to the parents’
attention • Has learning problems (or difficulty concentrating) that cannot be attributed to
specific physical or psychological causes • Is always watchful, as though preparing for something bad to happen • Lacks adult supervision Is overly compliant, passive, or withdrawn • Comes to school or other activities early, stays late, and does not want to go
home
Recognizing Child Abuse• The Parent:
• Shows little concern for the child • Denies the existence of—or blames the child for—the child’s problems in school or
at home • Asks teachers or other caregivers to use harsh physical discipline if the child
misbehaves• Sees the child as entirely bad, worthless, or burdensome • Demands a level of physical or academic performance the child cannot achieve• Looks primarily to the child for care, attention, and satisfaction of emotional needs
• The Parent and Child: • Rarely touch or look at each other • Consider their relationship entirely negative • State that they do not like each other
135
136
9/20/2020
69
Signs of Physical Abuse• Consider the possibility of physical abuse when the child
• Has unexplained burns, bites, bruises, broken bones, or black eyes • Has fading bruises or other marks noticeable after an absence from school • Seems frightened of the parents and protests or cries when it is time to go home• Shrinks at the approach of adults • Reports injury by a parent or another adult caregiver
There is currently legislation introduced (Assembly Bill 22) that would train commercial truck drivers on how to recognize signs of human trafficking.
137
138
9/20/2020
70
• Physical Indicators of Human Trafficking:
• While not all trafficking victims will show physical signs, some signs and symptoms should trigger further concern.
• Delayed care or an unexplained progression of an illness may be an indicator that a victim was denied access to care.
• Health care professionals may also note physical signs of long-term trauma, bruises in various stages of healing, signs of physical or sexual abuse, malnourishment, substance use, and poor hygiene.
• Labor trafficking victims, particularly those in high risk industries, may present with severe workplace injuries, prolonged and unprotected exposure to toxic chemicals, and exhaustion.
• Sex trafficking victims may report a high number of sexual partners, multiple STIs/STDs, multiple pregnancies, or request frequent STI/STD testing.
• Behavioral Indicators of Human Trafficking: • Some trafficking victims may not present many physical signs of
exploitation, but will exhibit behavioral concerns. • Some examples are scripted answers/stories, minimizing abuse or injuries,
overly fearful or nervous behavior, being unaware of location or date/time, being unwilling or hesitant to answer questions about the injury or illness, or symptoms related to depression or PTSD.
• Victims may also leave against medical advice or refuse care due to a potential trafficker using threats or manipulation to pressure the victim to return to work quickly.
139
140
9/20/2020
71
HIPAA Privacy
and
Security Training!
What is HIPAA?
• Acronym for Health Insurance Portability & Accountability
Act of 1996 (45 C.F.R. parts 160 & 164).
• Provides a framework for establishment of nationwide
protection of patient confidentiality, security of electronic
systems, and standards and requirements for electronic
transmission of health information.
142
141
142
9/20/2020
72
Why Comply With HIPAA?• To show our commitment to protecting privacy• As an employee, you are obligated to comply with [Insert Your ACC
Name] privacy and security policies and procedures• Our patients/members are placing their trust in us to preserve the
privacy of their most sensitive and personal information • Compliance is not an option, it is required.• If you choose not to follow the rules:
• You could be put at risk, including personal penalties and sanctions
• You could put your clinic at risk, including financial and reputational harm
143
HIPAA RegulationsHIPAA Regulations require we protect our patients’ PHI in all media including, but not limited to, PHI created, stored, or transmitted in/on the following media:
• Verbal Discussions (i.e. in person or on the phone)• Written on paper (i.e. chart, progress notes, encounter forms, prescriptions, x-
ray orders, referral forms and explanation of benefit (EOBs) forms• Computer Applications and Systems (i.e. electronic health record (EHR),
Practice Management, Lab and X-Ray• Computer Hardware/Equipment (i.e. PCs, laptops, PDAs, pagers, fax
• To use or disclose/release only the minimum necessary to accomplish intended purposes of the use, disclosure, or request.
• Requests from employees at your clinic:• Identify each workforce member who needs to access PHI.• Limit the PHI provided on a “need-to-know” basis.
• Requests from individuals not employed at your clinic• Limit the PHI provided to what is needed to accomplish the
purpose for which the request was made.
What is Minimum Necessary?
150
149
150
9/20/2020
76
What is Treatment, Payment and Health Care Operations (TPO)?
• HIPAA allows Use and/or Disclosure of PHI for purpose of:
• Treatment – providing care to patients.
• Payment – the provision of benefits and premium payment.
• Health Care Operations – normal business activities (i.e. reporting, quality
improvement, training, auditing, customer service and resolution of grievances
data collection and eligibility checks and accreditation).
HIPAA Definitions151
Patient Rights
Notice of Privacy Practices (NPP)• What is the purpose of the NPP?
• Summarizes how [ACC] uses and discloses patient’s PHI.
• Details patient’s rights with respect to their PHI
• The ACC must request that new patients sign the NPP acknowledgmentform at the time of their first visit.
• Patients sign the Acknowledgment of Receipt to confirm that they have been offered and/or received the NPP.
• If unable to obtain a signed Acknowledgement, the ACC must document its good faith efforts to obtain such acknowledgement and the reason why it could not obtain it.
152
151
152
9/20/2020
77
• Patient has the right to request to receive communication by
alternative means or location. For example:
• The patient may request a bill be sent directly to him instead of
to his insurance company.
• The patient may request we contact her on cell phone instead of
home telephone number.
Patient Rights
Request Alternate Communication
153
• Members of the workforce who handle PHI require training
• Required upon hire and recommended annually
• As material changes are implemented, training to appropriate
workforce members affected by that change
• Documentation of the training, who attended, the topic covered
and date the training was held
Training
154
153
154
9/20/2020
78
How Do Privacy Violations Happen?
➢ Fax Document to Wrong Location
➢ “Hello, this is Pizza Hut on Main Street. Did you
mean to fax me this X-ray report result for Fred
Flintstone?”
➢ Forgetting to Verify Patient Identity
➢ “There were seven patients with the name Barney
Rubble. I should have confirmed his date of birth.”
155
Release of InformationPermitted Uses and Disclosures of PHI Without Authorization
• Uses and disclosures of PHI for (TPO):• Treatment• Payment• Health Care Operations
• Disclosures required or permitted by law.• If use of the information does not fall under one of these categories you must
have the patient’s signed authorization (written permission) before sharing that information with anyone.
156
155
156
9/20/2020
79
Release of InformationIdentity Verification
• Prior to releasing PHI, ask the individual to provide you with enough information to identify the patient, such as:
• Name• Date of Birth• Address• Other identifiers: Social security number, mother’s maiden name
• Identify someone other than the patient by requesting he or she provide you with all the above information, as well as his or her relationship to the patient.
• Check a physical signature against a known one on file• Make a call-back to a known number• Ask for a photo ID• Ask for a business card
• Provide only the minimum necessary to safeguard PHI.
157
Release of InformationFamily and Friends
• Verbal disclosure of information permissible when:• Patient present and alert – patient decides• Patient incapable to make wishes known – inferred permission to
discuss current care• Needed for care or payment
• Information needed for patient’s care• Family member/friend must clearly be involved in payment for care
(involvement is obvious, patient stated so)
• Notify family or friend(s) who are involved in patient’s care of:• Patient’s general condition• Patient’s location• Patient being ready for discharge• Patient’s death
Disclosures of this nature exclude paper
copies
158
157
158
9/20/2020
80
Release of InformationDivorced Parents
• A divorced parent calls to get information on their child. Can you release it?• If the parents are divorced, either parent may get access to the
records with a proper release. Assume that they can get records unless told otherwise.
• When parental rights are in question:• Obtain the court documents for the child’s file from one of the
parents.• If parental rights for physical placement have been terminated,
Wisconsin law allows only the parent with sole physical placement to access records.
159
Release of InformationLegal Guardians
An individual calls to discuss appointment information with you for a patient and
states he is the patient’s legal guardian. May I discuss with the individual?
• Yes, after obtaining the court documents appointing the individual as
the patient’s Legal Guardian.
• Make a copy of the court documents for the patient’s file.
• Confirm that the information being provided is appropriate and
necessary.
• If unable to obtain court documents verifying legal guardianship, do
not discuss PHI with the individual.
160
159
160
9/20/2020
81
Release of InformationStep-Parents
A step parent calls to discuss her
stepchild’s care. May you discuss this
with her?
• No, unless the step-parent is a
legal guardian and has the
guardianship papers on file, or
a legal guardian has provided
authorization.
• Step-parents may call to
schedule appointments, but do
not have access to their
stepchildren’s PHI without
authorization by a legal
guardian.161
Release of InformationDisclosure of Workers’ Compensation PHI to Employer
• What information can be disclosed in response to a Workers’
Compensation request?• We may disclose only those records reasonably related to the
Workers’ Compensation claim/condition without an
authorization
• Patient’s written authorization is required to release any PHI
unrelated to the Workers’ Compensation claim
162
161
162
9/20/2020
82
Release of InformationTo Another Facility
• Can I release a patient’s address and/or insurance information to a nursing home?
• Yes, if you know the requesting individual and the request is legitimate
• If you are unfamiliar with the individual requesting the information, ask for the following in writing:
• Patient’s name, date of birth, and address• Why the information is needed• Specific reason (e.g. treatment or payment)• The requestor’s name, name of the nursing home, and a direct telephone to
the nursing home (switchboard)
• If uncertain, obtain patient authorization
163
Release of InformationLeaving Messages
• A spouse answers the phone, or voice mail picks up. What information may I provide? • State your first name and that you are calling from [Clinic Name]
(include the site... If more than 1 location).• Ask the patient to return your call, and provide your direct phone
number.• Example: “This is Sally from [Clinic] calling for Johnny Doe. Please
call me back at your earliest convenience at [number]. Thank you.”• Ensure call is disconnected.
164
163
164
9/20/2020
83
Release of InformationFaxing PHI
• May PHI Be Transmitted via Fax Machine?• Yes, but only when in best interest of patient care or payment of
claims.• Faxing sensitive PHI, such as HIV, mental health, AODA, and
STD’s is strongly discouraged.• It is best practice to test a fax number prior to transmitting
information. If this is not possible:• Restate the fax number to the individual providing it.• Obtain telephone number to contact the recipient with any questions.• Do not include PHI on the cover sheet.• Verify you are including only correct patient’s information (i.e.
check the top and bottom pages).• Double check the fax number prior to transmission
165
Safeguarding PHIDisposal
• How should I dispose of confidential paper?• Shred or place all confidential paper in the designated
confidential paper bins.
• How should I dispose of electronic media (CD, USB Drive, etc.)?
166
165
166
9/20/2020
84
Business Associate Agreements
167
Business Associate Agreements• If you initiate negotiations to contract with a company to perform, or assist
in the performance of a function or activity involving the use or disclosure of PHI, please contact the [Privacy Officer] to obtain a Business Associate Agreement (BAA).
• Examples of when to obtain a BAA with a company include:• Claims processing or administration, data analysis, processing or
administration, utilization review, quality assurance, billing, benefit management, practice management, and repricing; and
• Legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.
168
167
168
9/20/2020
85
Scenarios
169
170
9/20/2020
86
Scenarios
#1
I Was Just Concerned!
• Your co-worker, Joan, hasn’t been at work the last 3 days and you’re starting to get worried about her. You consider her a friend and conclude she’d be hurt if you don’t call her. You don’t have her phone number. But it’s in the electronic medical record! You, log on and look up Joan’s phone number. Is this ok?
171
172
9/20/2020
87
NO…
• Consider This: While looking up her phone number you notice she has a diagnosis of breast cancer on her problem list.
Scenarios
#2
173
174
9/20/2020
88
Scenario
• An 18-year-old high school senior at CHUSA High School gets injured at gym class. She is having Low Back pain and her best friend, who is a current patient, takes her to your clinic.
• A few days later her mother reads a text about her low back pain on her phone and angrily calls your clinic, demanding more information.
• The front desk team member confirms that her daughter visited the office for an a sprain of the lower back.
• Policy and Procures • The team member violated HIPAA and could be fired. Because she is 18, the
girl’s mother does NOT have any legal rights to her medical information (unless the daughter signed a consent form giving her mother the rights, which seems highly unlikely in this case).
• Please check with state law.
175
176
9/20/2020
89
Scenarios
#3
I Just Needed a Gallon of Milk!
• You’re a CT. This morning you saw 6-year old, Allison for a rapid strep test. On the way home from work you you stop at Viking Village (local grocery store) for a few things. Walking through the Frozen Foods, you run into Allison’s mom, Sherry.
• “I’m so glad I ran into you! Did you get the strep results yet? It would be great if I knew now so I could call her primary and get her in this afternoon and back to school sooner”. Can you disclose to Allison’s mom?
177
178
9/20/2020
90
No…
• Can't disclose any information.
• Please contact the clinic
• Check with State Laws
Scenarios
#4
179
180
9/20/2020
91
I Have a Right to Know!
• Mr. Albertson is on the phone. He states his wife was in the
clinic yesterday for X-rays and he wants you to tell him the
results of the immediately. He is very angry! “I have a right to
know since I pay the bills. Your Front Desk team brings up the
report and shares it with him.
No this is a violation• Your Team violated HIPAA UNLESS the woman had
signed a consent form, giving her husband access to her medical information (which many women do). OTHERWISE, the team member would ONLY be authorized to tell the woman herself the information, not to tell it to the her husband or even leave it on an answering machine
• Unless authorization has ben given , you can’t discuss the situation
• “I can not confirm no deny due to HIPAA privancy”
181
182
9/20/2020
92
Scenarios
#5
Scenario
• Two Chiropractic Team Members who work at CHUSA Chiropractic Clinics are shopping together at Wal-Mart after work.
• As they walk around, they talk about their patient Barbara. • She’s was in the clinic today for treatment, they discuss how her back pain is
due to her being extremely overweight , and her house on Main street is a dump.
183
184
9/20/2020
93
Answer
• The Team members DID violate Barbara’s rights because they spoke about her IN PUBLIC and used IDENTIFYING INFORMATION (her first name), that she lived on main street, and discussed her case.
Scenarios
#6
185
186
9/20/2020
94
Mrs. Anderson called CHUSA Family Chiropractic and ask if they received her new patient forms, x-rays and lab results. A team member confirmed the email [email protected], and that they received the information.
• The Privacy Rule allows sharing of PHI electronically (or in any other
form) for treatment or payment purposes, as long as reasonable
safeguards are applied.
• The Security Rule does not expressly prohibit the use of email for
sending electronic PHI. However, the standards for access control,
integrity and transmission security require covered entities to implement
policies and procedures to restrict access to, protect the integrity of, and
guard against the unauthorized access to electronic PHI sent and
received over email communications. A covered entity must assess its
use of open networks, identify the available and appropriate means to
protect e-PHI as it is transmitted, select a solution, and document the
decision.
• The Security Rule allows for e-PHI to be sent over an electronic open
network as long as it is adequately protected. For example, if you don’t
use a secure, HIPAA compliant email application, avoid including PHI in
the text of email, and encrypt any files containing PHI.
• It’s easy enough to get a Gmail account. With over a billion active users, it’s clear that Gmail is the most active e-mail service in the world. Here-in lies the issue: this type of personal email is not compliant.
• What makes email HIPAA compliant?• To be compliant, an email provider must sign a Business Associate Agreement (BAA). A
BAA is a contract between the healthcare provider and anyone they do business with that will have access to protected health information.
• Email, or more specifically an email server, is a perfect example of a third party who would have the opportunity to gain access to patient information. Therefore, any email provider that wants to support a healthcare institution must be willing to sign a BAA.
• The issue with using an out-of-the-box Gmail account that you or I can sign-up for is that Google is unable to sign a business associate agreement baa. Not having a BAA means you’re not HIPAA compliant.
G Suite for Business Users
• Fortunately, Google offers additional services to businesses. GSuite is a collection of the most-used Google apps for business, including Gmail, Google Drive, and Google Calendar, specially packaged for enterprises. GSuite must be associated with a domain that the user owns and is a paid service.
• Although GSuite gives users access to Gmail, the most significant difference lies in Google’s ability to sign a BAA. This means that healthcare providers who wish to use Gmail as an email service for their company have the opportunity to purchase GSuite, link it to their company’s domain, and handle the technology component of the solution triad.
• But not so fast: this does not create a HIPAA compliant solution. There’s more to do after a BAA is signed to ensure that all patient data that would be shared over email is protected. Encryption is a critical component of verifying that patient information is safe when being transmitted via email.
• Think of it in terms of achieving two goals:• Validate that you are only communicating with the intended party. This falls under the Privacy
Component. By using PKI infrastructure and the encryption of the email using the patients Public Key, you can increase the level of confidence in the “privacy” of this communication.
• Confirm that the transmission cannot be intercepted. This component falls under Confidentiality. This is where encryption plays a role. As the communication is encrypted via the patients Public Key, only the patient can decode the message using their Private Key.
While waiting for a patient to exit the restroom, to place in a treatment room, a team member at CHUSA chiropractic accidentally overheard discussing a client’s PHI a the front desk
191
192
9/20/2020
97
• It is not a violation as long as you were taking reasonable precautions and were discussing the protected health information for a legitimate purpose. The HIPAA privacy rule is not meant to prevent care providers from communicating with each other and their clients during the course of treatment. These "incidental disclosures" are allowed under HIPAA.
Scenarios
#8
193
194
9/20/2020
98
• A tornado has hit your local town. Your clinic has been damaged. A patient has reached out to get their records as they have left the area and would like to continue care. You tell them that the clinic is damaged, and you can’t get to their records.
• This is a violation
• You should have had a disaster recovery procedure in place.
• The HIPAA security rule requires a policy be in place and staff trained in
case of fire, vandalism, system failure or a natural disaster that damages
systems that contain electronic protected health information. A disaster
recovery plan and procedure is required to restore any loss of data, and
provide records when requested in a timely fassion.
195
196
9/20/2020
99
Scenarios
#9
• Sally a Chiropractor at CHUSA Family Chiropractic , had a long day and brought her laptop to her favorite coffee spot to work on patient notes, as she needs to get them done in 48 hours.
197
198
9/20/2020
100
This may be a problem
• Do workforce members with laptops take the system home or out of the office?
• One of the leading causes of ePHI data breaches is lost laptops and portable
media.
• Laptops that contain ePHI should be tracked, and only authorized workforce
members should be allowed to remove them from an organization’s offices.• Most physicians have computers they use from home to access the clinic system and
gather information about patients.• If the computer screen is accidentally left openor if family members share the computer,
it is a HIPAA violation. • If a home computer is used to access the hospital system, it must be password protected
with a code that only the physician knows. If the computer is a laptop, transport from home to office also poses a risk. Always transport laptops hidden out of sight, ideally locked away in the trunk, to decrease the risk of patient information being accessed and stolen.
Scenarios
#10
199
200
9/20/2020
101
• Bill loves to post and view on tick tok . He works in the rehab area of CHUSA Chiropractic.
• He loves his job and posts to his followers about his day.• He is very careful not to post about patients. • He uses his office computer.
• Are workforce members aware of workstation use policies that prohibit
online activities such as email, social networks, etc.?
• The HIPAA security rule states that all workforce members should be made
aware of proper workstation use. Implement policies and procedures that
specify the proper functions to be performed, the manner in which those
functions are to be performed, and the physical attributes of the
surroundings of a specific workstation or class of workstation that can
access electronic protected health information.
201
202
9/20/2020
102
Scenarios
#11
• James has been a friend of Dr Toms since they were in 1st grade.
• James had his vitals preformed today and wanted to know his blood pressure.
• James texts Dr Tom and askes him what his blood pressure was, Is this a violation?
203
204
9/20/2020
103
• Texting patient information –• We live in an era of texting and physicians are no exception. Patient
information such as test results or vital signs and symptoms are often communicated over text. Texting often results in quicker delivery of patient care – which seems harmless, but it means that the patient’s health care information now exists in cyberland and hackers may access this information.
• New encrypted programs have come out that allow confidential information to be safely texted, however all parties must have the system on their phones, and use it. This is an expense that many clinics are reluctant to take on.
Scenarios
#12
205
206
9/20/2020
104
• Krista saw Susan at your clinic when she was walking out after her massage. You go to your son’s baseball game in your small town and sit next to Krista. Krista inquires about Susan and her lower back issues….
• Breaches in social situations – Accidental confidentiality breaches are especially common for physicians in small towns where everybody knows everybody.
• The average citizen is generally not aware of HIPAA laws and may make an innocent inquiry in social settings such as at church or community events.
• For example, “I saw Joan Smith in your office yesterday, I hope she’s not having problems with her back again.” An innocent inquiry, though responding with any specific information is a violation.
• The physician’s best solution is to have a rehearsed comeback phrase prepared that they are comfortable with, such as, “I know Joan would appreciate seeing you, why don’t you give her a call or stop by her house for a for a visit.”
207
208
9/20/2020
105
Scenarios
#13
• Courtney, a Team Member at CHUSA chiropractic, had a written and signed request to fax a patients record request to them at work, she calls the patient, verifies his name and date of birth, the fax number, and sends the fax. Courtney calls and verifies that the fax was received by the patient that requested the information.
209
210
9/20/2020
106
• You must have in place reasonable and appropriate administrative,
technical and physical safeguards to protect the privacy of protected
health information that is disclosed using a fax machine.
• Examples of measures that could be reasonable and appropriate include
confirming that the fax number to be used is the correct one, using a fax
cover-sheet that does not contain PHI, and placing the fax machine in a
secure location to prevent unauthorized access to the information.
• Additional safeguards should be considered when faxing highly
confidential information.
Scenarios
#14
211
212
9/20/2020
107
• Smith Chiropractic loves posting pictures on Facebook with their patients, especially newborn babies, after they are finishing up with their treatment plan.
• Social media is undeniably woven into the fabric of our daily lives, however it can cause problems for physicians who are charged with protecting their patients’ privacy and therefore must be avoided.
• Posting patient photos is a common violation. Even if the patient’s name is not shared, a Facebook or Twitter friend may recognize the patient and know the physician’s specialty and suddenly a patient’s privacy has been violated.
213
214
9/20/2020
108
Scenarios
#15
• Assuming the auto lock would activate soon, Dr Smith at CHUSA sports
chiropractic did not lock his computer when he left the patient in an treatment
room.
• While waiting, the patient got bored and looked at his electronic record. Not only
did the patient see his and diagnosis of lumbar facet syndrome, but he also read
that his mother has breast cancer and her prescription list for Prozac.
216
215
216
9/20/2020
109
• Walking away from your computer without locking or logging off your workstation is a violation. Walking away and leaving a computer unlocked which allows ANYONE to access Protected Health Information (PHI) is a serious violation.
• One of the simplest tricks I’ve ever shown people is the “Windows+L” command (pressing the special Windows symbol key and “L” at the same time). It is the “Lock” command built into Windows for many years now. Using it will “Lock” the computers console, leaving the computer at “Locked” screen message. When you return to the PC, you will be required to re-enter your Windows password to start using the PC again. Locking does not log you off, but merely locks the screen so someone can’t see what was on screen or use the computer. If you were in the middle of creating Document when you walked away and locked it, you’ll be in the exact same place when you unlock it. The Windows+L keystroke is very easy to learn and use – your staff can start using it today immediately after you show them about it.
• What is your clinic policy on locking computers?
• What is your clinics policy for patients to request copies of their records?
Scenarios
#16
217
218
9/20/2020
110
• CHUSA Chiropractic Clinic calls their patients to remind them of their appointments, and for patients who schedule well in advance postcard reminders.
• Yes. The Privacy Rules allow this type of patient communication, but
precautions must be taken to safeguard the patient’s privacy. For example,
answering machine messages should be limited to the appointment time or to
request that the patient return the call. The Privacy Rules also allow messages
to be left directly with the patient’s family member or companion.
• Doctors are allowed to disclose information about the patient’s care to the
patient’s family members and friends, even if the patient is not present or has
not affirmatively given the physician permission to do so, as long as the doctor
believes that the disclosure is in the patient’s best interest. If the patient has
expressly directed that there be no disclosure to specific family members or
friends, however, the patient’s wishes must be respected.
• Also, if a patient requests confidential communications, the request must be
accommodated if it is reasonable. For example, it would be reasonable for a
patient to request that all mailings be sent to a specific address (e.g., to the
patient’s office instead of home, or vice versa), or be sent in a closed envelope
instead of on a postcard.
219
220
9/20/2020
111
Scenarios
#17
• “Jane Jones,” who was quite wealthy, well-known and active in her community, had undergone breast augmentation surgery with a plastic surgeon. She revealed this information to her Doctor of Chiropractic before receiving care, and asked the D.C. to keep it confidential. The D.C. noted this information in the charts.
• Several months later, another woman considering the same surgery was confiding in a CA at that chiropractic practice. The CA unthinkingly told the woman: “You know Jane Jones, don’t you? Why don’t you give her a call? She had the same surgery last year.”
221
222
9/20/2020
112
• Clearly, doctor/patient confidentiality is essential as it enables patients to freely share needed information with the doctor.
• Doctors—and the people they employ—are expected to protect this confidential patient information and only use it on behalf of the patient. This expectation of confidentiality starts when the doctor/patient relationship begins. When this confidentiality is violated, patients may sue.
• Consider what could happen in a scenario like the one described earlier. It is very possible Ms. Jones would retain an attorney and possibly file a lawsuit for alleged breach of confidentiality for the actions of the CA. As the employer, the doctor and/or the practice could be held vicariously liable for the unauthorized disclosure of patient information by one of its employees.
• Breaches in patient confidentiality can have long-term adverse effects, even when no lawsuit is filed. First and foremost, patients lose trust over having the private information they shared becoming public knowledge. The practice’s reputation can be permanently damaged by any negative publicity about the breach, resulting in lost patients and revenue.
• A chiropractic practice cannot afford to give patient confidentiality the short shrift. At minimum, a practice’s efforts should include:
• Defined policies and procedures, which require employees at all levels to protect personal health information from unauthorized or unnecessary disclosure. These should include defined disciplinary actions for employee non-compliance with these policies. Many practices have implemented “zero-tolerance” policies for breaches in patient confidentiality, with violations resulting in immediate suspension or even termination of employment.
• A confidentiality agreement signed by all practice employees (including temps) upon hiring. Employees must agree to abide by these policies and procedures.
• New-employee orientation and training sessions addressing patient confidentiality and the practice’s commitment to protecting patients’ healthcare information.
• Recurring staff in-service programs on patient confidentiality. These should teach, through case scenarios and role playing, the importance of:• Confining discussions to patient care areas• Intolerance of staff gossip and inappropriate disclosure of personal health information• Being sensitive about who can overhear or view: discussions, phone conversations, computer
screens, unfiled clinical charts, patient records received via fax, etc.• Adhering to the practice’s policies and procedures
223
224
9/20/2020
113
Want to know more about HIPAA?
U.S. Department of Healthand Human Services
www.hhs.gov/ocr/hippaIf you have questions or need additional information, visit the official website
and take advantage of frequently updated resources there.
225
226
9/20/2020
114
• Much like with our own chiropractic skills, the more frequently we practice, the better we become.
• We should consider conducting quarterly office trainings and completing the certification at least once a year. (Compliance Manual)
• In my experience, when people complete the certification within this time frame, their memory and ability to perform these skills is that much sharper.
• We know that the more we practice, the more it will become engrained in our minds.
• If we ever come across an emergency situationin our office or out in public, we will be able to react quickly and increase the chances of saving a life
227
228
9/20/2020
115
• According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud financial losses are in the tens of billions of dollars each year. In 2018, The US HHS and The Department of Justice recovered more than $14.3 billion in healthcare fraud and abuse. As medical fraud rates continue to soar, healthcare providers should expect to see an increase in governmental inquires, audits, and investigations.
• For medical practices, an effective compliance program can be the first line of
defense. The purpose of a compliance program is to promote the prevention of criminal conduct, enforce government rules and regulations, while providing quality care to patients
• With fraud enforcement initiatives increasing, medical practices that have notimplemented compliance plans risk exclusion from commercial insurance plans and government healthcare programs.
• According to CMS, the implementation of a good compliance program will aid in better protecting a practice from the riskof improper conduct.
Seven Elements of Your Compliance Program
• 1. Designate a compliance officer• 2. Conduct comprehensive training and education• 3. Implement Written Policies and Procedures• 4. Conduct internal monitoring and auditing• 5. Develop accessible lines of communication• 6. Enforcing standards through well publicized disciplinary guidelines• 7. Responding promptly to detected offenses and undertaking corrective actions.
229
230
9/20/2020
116
• By implementing a comprehensive compliance program, a practice can find and correct potential vulnerabilities while minimizing billing mistakes, reducing the chance of an audit, increasing payment of claims, reducing the chance of fraud and abuse, and promoting safe and quality
care. Healthcare providers that have not yet implemented a compliance plan should utilize the seven core elements as a foundation for their program.
If you can't fly, then RUN. If you can't run, then WALK.
If you can't walk, then CRAWL.
But whatever you do,
YOU HAVE TO KEEP MOVING.
Martin Luther King, Jr. – Civil Rights Activist and Pastor
231
232
9/20/2020
117
Medicare cards Are HERE
The new Medicare card contains a unique, randomly-
assigned number that replaces the current Social
Security-based number.
The new Medicare cards, issued by CMS, will have a
unique, randomly-assigned number called a Medicare
Beneficiary Identifier (MBI) that will replace the existing
Social Security-based Health Insurance Claim Number
(HICN).
Please remind your Medicare Patients!!!!!• Need to use Medicare Beneficiary
Number (MBI)
• [11 letters and numbers)
• not SSN
• Mailed out in Batches
1.The overall card design has been changed enough to make it easy to distinguish from the old card. This will reduce chances your staff might submit an old card after the transition date (which would delay payment).2.The Medicare 800 number has been removed (this appears on the back of the new card,).3.Gender designation has been removed from the card4.The old number was comprised of your social security number followed by the letter “A”; the new number is a random series of numbers and capital letters.5.The term “Effective Date” has been changed to “Coverage Starts” but the meaning is the same.6.The Hospital/Medical designations have been removed from the new card leaving just the references to Part A and Part B.7.The signature line has been removed..8.The new card offers information descriptions in both English and Spanish.
233
234
9/20/2020
118
New vs Established Patients
• Per CMS…• A new patient is one who HAS NOT
received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past
three years.
Emergencies That Can Present to a Chiropractic Office
235
236
9/20/2020
119
• It is essential to understand that there is a critical period of time between when the patient becomes unresponsive due to an event and the time that it takes for the paramedics to arrive on scene following a 911 phone call.
• This time frame is typically between five and 10 minutes, but also depends on the area where you are located.
• In a more rural area, the time for emergency personnel to arrive at scene could be longer.
• During this waiting period, it is crucial that CPR be started and an automated external defibrillator (AED), if available, be used.
Every minute that passes during a
cardiac arrest decreases the chance
of survival by seven to 10 percent.
Beyond 10 minutes, CPR is rarely
successful, according to The Heart
and Stroke Foundation
• This is why it is vital to attach the AED as soon as possible.
• I always recommend that chiropractic offices be equipped with an AED.
• An AED can be applied to the individual within minutes, which will drastically increase the chance of survival.
237
238
9/20/2020
120
• Having an AED in your clinic provides you, your staff and your patients the confidence that you have the necessary equipment to use in an emergency.
• Our patients will appreciate the extra effort we've put in. They are already confident in our ability to help them achieve their optimal health, now they can also be confident that we are ready to respond to an emergency, should one arise.
• Now that chiropractors are required to have up-to-date first aid and CPR training, it shouldn't stop there.
• It is critical that the office staff are trained as well. Our office staff are the face of our practice. • They are the first ones to greet the patient when they come into the office. • Typically, the patient will tell them how they are doing that day. • What if the patient begins telling the receptionist the signs and symptoms they're experiencing? • What if the emergency doesn't occur in the treatment room, but occurs in reception area, instead? • Is the receptionist ready to deal with an emergency scenario? • What if the chiropractor is not in one day but there are other practitioners, such as a massage
therapist, treating that day. • If an emergency occurs, are these individuals prepared?
• This is why I encourage all office staff to be trained, not just the chiropractor. We will have more confidence knowing that if an emergency situation arises when you are not present, your office staff will be able to effectively handle it.
239
240
9/20/2020
121
• Imagine this for a moment. A person becomes unconscious and is no longer breathing in either your treatment room or in your reception area. You first have to call 911 and call for an AED. At this point you have approximately ten minutes until the paramedics will arrive. Now, you must start CPR, apply the AED and maintain some small crowd control for any patients that may be waiting in the office or crowding around the scene.
In this situation, you require a couple of minutes to call 911 and a couple of minutes to get an AED. This is valuable time that is wasted, if you are performing this all by yourself. Having a staff member that you can rely on during an emergency is very important.
How will your office respond to :
• Heart Attack• Stroke• Patient/team member fall or injury• Loss of conscience Dizziness, Fainting• Active labor • Difficulty Breathing• Choking• Bleeding• Diabetic Emergency'sHave policies in place and train annually on how they are to be handled
241
242
9/20/2020
122
Medical Emergencies
General Breathing Problems
• Is breathing very fast or slow• Is having trouble with every breath• Has noisy breathing• Can only make sounds or speak no more than a few
words at a time in between breaths
243
244
9/20/2020
123
Helping with Breathing Problems
Helping a Choking Adult• If someone is
choking, they might use the choking sign
245
246
9/20/2020
124
Helping a Choking Adult
Adult Choking (Other Options)
DEMO
247
248
9/20/2020
125
Child Choking
• Remember if they can cry speak, etc.. they are not choking
Call EMS
• Make Sure The Scene
is Safe
• Activate EMS
• Get First Aid Kit and
AED(Just in case)
• Get the victim
comfortable
Heart Attack
Call EMS
249
250
9/20/2020
126
Allergic Reactions
• People can be allergic to many things, including:• Foods such as eggs,
nuts, and chocolate• Insect stings or bites,
especially bee or wasp stings
Using Epinephrine Pens• Will help someone with a severe
allergic reaction breathe more easily• Contains a small amount of medicine
that can be injected through clothing• Takes several minutes before the
medicine starts to work• Injection is given in the side of the thigh
251
252
9/20/2020
127
Child (EPI JR) VS Adult Dose
EPI Pens
Using Epinephrine Pens
Call EMS
253
254
9/20/2020
128
Shock
Call EMS
Diabetes and Low Blood
Sugar
255
256
9/20/2020
129
• First stage: The time of the onset of true labor until the cervix is completely dilated to 10 cm.
• Second stage: The period after the cervix is dilated to 10 cm until the baby is delivered.
• Third stage: Delivery of the placenta.
Stages Of Labor: Early Labor, Active Labor & Transition Stage
How long do you
need to keep records?
257
258
9/20/2020
130
How long should you keep medical records?
• It is interesting to note that HIPAA rules and regulations do not include medical record retention requirements. Rather, other federal and state laws regarding record retention apply.
• HIPAA rules do require that you utilize appropriate administrative, technical, and physical safeguards to protect the privacy of information for as long as you maintain records. Our
• guidance at the WCA Help Desk is to retain medical records, including electronic records for at least seven years. This is because the regulations defining “unprofessional behavior”
• of a chiropractor contained within the Wisconsin Administrative Code include, “failing to maintain records for a minimum period of 7 years after the last treatment or after the
• patient reaches the age of majority, whichever is greater.” Wis. Admin. Code Chir6.02(27). For the complete statutes, visit: http://docs.legis.wisconsin.gov
• The American Health Information Management Association (AHIMA) recommends providers keep adult patient health records for 10 years after the most recent encounter. For
• minors, the recommendation is until the age of majority plus the statute of limitations. Because electronic records make longer periods of storage possible, you could exceed these guidelines. However, please note that if you keep records, you must produce those records when asked. Furthermore, the longer you keep records beyond there commended retention period, the greater chance those records will be subject to a breach that may then require you to report to the individuals affected by the breach.
259
260
9/20/2020
131
How long should you keep medical records?
261
262
9/20/2020
132
263
264
9/20/2020
133
Evaluation and Management Guidelines (E/M) 2021
• The NEW Guidelines will take effect on January 1, 2021, pending
ratification of the final rule by CMS. The E/M changes only apply to Office
and Outpatient Service CPT Codes (99201 – 99215).
• Since the origination of the 1995 guidelines, evaluation and management
coding has been difficult. Attempts were made to alter the guidelines in
1997. Although the guidelines were adopted, thing have never been right,
until 20121.
• Maybe?
265
266
9/20/2020
134
Effective January 1, 2021
• The aim of the framers for the NEW 2021 E&M Guidelines:
• Reduce administrative burden of documentation and
coding.
• Reduce the need for audits, by adding more detail to
CPT codes to promote coding consistency.
• Reduce unnecessary documentation that is not needed for
patient care.
• Ensure that payment for E/M is resource-based and that there
is no direct goal for payment redistribution between
specialties.
Say Goodbye To 99201
• The AMA is planning to delete 99201 from the E/M code set. If
you think about it, you may comment, “It’s about time!” Why
would you submit a claim for a new patient examination that
does not require the presence of the physician? This is an official
code deletion, meaning it will no longer appear in the code book
after 2020.
• • There are some situations in which you may still need to report
99201, such as those entities that will not immediately adopt the
• The non-face-to-face time takes into account the time the provider utilizes to
prepare the case, such as review of medical records, and the time taken by
ancillary staff in consultation prior to the face-to-face encounter.
Time Elements in the 2021 E/M Guidelines
• In case of an audit, if the provider is utilizing time to determine the level of
the E/M service, the time will have to be justified and documented. An
estimation of time will not be enough.
• Minutes spent on the following activities can be billed as E/M services:
• • Reviewing tests in preparation of a patient visit.
• • Obtaining and/or reviewing a separately obtained history.
• • Performing a medically necessary appropriate examination
and/or evaluation.
• • Counseling and educating the patient, family, or caregiver. – Q:
Will this include the report of findings? A: ________
• • Ordering medications, tests, or procedures.
273
274
9/20/2020
138
Medical decision-making coding is based on the:
• – Number and complexity of problems addressed at the
encounter.
• – Amount and/or complexity of data to be reviewed and
analyzed.
• – Risk of complications and/or morbidity and mortality
of patient management.
Time Documentation for the 2021 E/M Guidelines
• For CPT® Codes 99202-99215
• • This is for the TOTAL TIME on the DATE OF THE
ENCOUNTER
• • Time personally spent by the physician and staff on the day
of the encounter – Includes time spent by qualified health
care profession
• – Includes time spent by the doctor
• – DOES NOT include time by clerical staff at Front Desk
275
276
9/20/2020
139
Activities the Count as Timed Activities
• • Preparing to see the patients such as review of tests X-ray, MRI, lab.
• • Obtaining or reviewing a separately obtained history (referral).
• • Performing a medically appropriate examination or evaluation.
• • Counseling and educating the patient/family/caregiver.
• • Ordering medications, further tests, or procedures.
• • Referring and communicating with other health care professionals.
• • Documenting clinical information in the electronic or other health care
record.
• • Independently interpreting results and communicating the results to the
patient/family/caregiver.
• • Care coordination.
Evaluate the Time You Spend Now
• Since time may be used to determine the level of E/M
service, it would be wise to begin now to evaluate how
much time is spent on the activities below. After all, it
takes time to evaluate time!
• Currently, list how much time it takes for you to do the
following activities.
• As an exercise, evaluate your total time taken in several
new patients.
• You can then realize that the differing times will
translate into different levels of service.
277
278
9/20/2020
140
How much time do you spend to do each of the following?
• • Preparing to see the patients such as review of tests.
• • Obtaining or reviewing a separately obtained history.
• • Performing a medically appropriate examination or evaluation.
• • Counseling and educating the patient/family/caregiver.
• • Ordering medications, tests, or procedures.
• • Referring and communicating with other health care professionals.
• • Documenting clinical information in the electronic or other health care
record.
• • Independently interpreting results and communicating the results to the
patient/family/caregiver.
• • Care coordination.
• This table is only for outpatient services. The pre-service, service, and post-
service times are added up to arrive in the total time taken for the
encounter.
CODE TIME RANGE
(Minutes)
99202 15 – 29
99203 30 - 44
99204 45 - 59
99205 60 - 74
99212 10 - 19
99213 20 - 29
99214 30 - 39
99215 40 - 54
279
280
9/20/2020
141
Record Request Fees
Charging for records
• Health Care Provider Records Fees
• JULY 1, 2018 TO JUNE 30, 2019
• Decision Tree
• Are you a provider who transmits health information electronically?
• No (e.g., cash-only practice, no HER, Paper Note, Paper mailed Claims)
• Use Wisconsin Fees
281
282
9/20/2020
142
• Wisconsin Fees Under Wis. Stat. 146.83(3f)(a), health care providers must provide medical records “if a person requests copies of patient’s health care records, provides informed consent, and pays the applicable fees.” To provide
“informed consent” under 146.81(2), the request may be “signed by the patient or a person authorized by the patient.”
• Each July 1, the Wisconsin Department of Health Services will adjust the dollar amounts that a health care provider may charge for providing copies of a patient’s health care records. The current fees are listed on this page, and are also available at dhs.wisconsin.gov.
• Sales Tax: Sales of paper copies of patient medical records are no longer subject to Wisconsin sales or use tax if the medical records are sold to the patient or a person authorized by the patient to receive the medical records
Wisconsin Fees
• Pursuant to Wis. Stat. §146.83 (3f) (c) 2., each July 1, beginning on July 1, 2012, the Department of Health Services is required to adjust, by the percentage difference between the consumer price index for the 12-month period ending on December 31 of the preceding year and the consumer price index for the 12-month period ending on December 31 of the year before the preceding year, the dollar amounts specified under Wis. Stat. §146.83 (3f) (b) that a health care provider may charge for providing copies of a patient’s health care records. Under the methods prescribed in Wis. Stat. §146.83 (3f) (c) 2., the adjusted dollar amounts that a health care provider may charge for providing copies of a patient’s health care records are as follows:
283
284
9/20/2020
143
• Are you a provider who transmits health information electronically?
• YES
• Charge the lower of the HIPAA Rate or Wisconsin
Fees.
285
286
9/20/2020
144
Medical Assistance:• A health care provider may not charge a patient or a person authorized by the
patient more than 25% of the applicable fees for providing one set of copies of a patient’s health care records if the patient is eligible for medical assistance. A health care provider may require that a patient or person authorized by the patient provide proof that the patient is eligible for medical assistance before providing copies at a reduced charge. A health care provider may charge 100% of the applicable fee for providing a second or additional set of copies of patient health care records for a patient who is eligible for medical assistance (Wis. Stat. 146.83(1f)(cm)).
Social Security:
• If a patient or person authorized by the patient requests copies of the patient’s health care records for use in determining eligibility for or appealing a denial of social security disability insurance or supplemental security income, the health care provider may charge no more than the amount that the Federal Social Security Administration reimburses the department for copies of patient health care records (Wis. Stat. 146.83(1f)(am)(bm)).
287
288
9/20/2020
145
Worker’s Compensation Records:
• The allowable charges for copies of certified medical records are the greater of 45 cents per page or $7.50 per request plus the actual cost of postage.
• Neither a retrieval fee nor a certification of records fee may be imposed.• An employee who reports a work-related injury waives any physician-patient
privilege with respect to any condition reasonably related to the condition for which the employee claims compensation.
• As of March 2016, providers may not charge more than $26 for Workers Compensation records requested in electronic format. See 2015 Wis. Act 180.
HIPAA Rate• Under HIPAA, individuals have an enforceable right to see and receive copies of
health records upon request . HIPAA limits the types of costs that may be imposed by “covered entities” for providing copies of patient health records that are initiated by the patient. A “covered entity” includes a health care provider who “transmits any health information in electronic form.” A covered entity must provide the individual with access to protected health information in the form and format requested by the individual (paper or electronic), if it is readily producible in such form and format; or, if not, in a readable hard copy form or such other form and format as agreed to by the covered entity and the individual. HIPAA permits a covered entity to impose a reasonable, cost-based fee if the individual requests a copy of his/her protected health information.
289
290
9/20/2020
146
Fees are limited to the actual cost of the following:
• 1. Labor for copying the protected health information requested, whether in paper or electronic form2 ;
• 2. Supplies for creating the paper copy or electronic media (e.g., CD or USB drive) if the individual requests that the electronic copy be provided on portable media and the covered entity maintains the records electronically;
• 3. Postage, when the individual requests that the copy, or the summary or explanation, be mailed; and
• 4. Preparation of an explanation or summary of the PHI, if the individual in advance both chooses to receive an explanation or summary and agrees to the fee that may be charged.
• When an individual makes a medical records request, copying fees “may not include costs associated with verification; documentation; searching for and retrieving the protected health information; maintaining systems; recouping capital for data access, storage, or infrastructure, or other costs not listed above, even if such costs are authorized by State law.”
Electronic Records
• Because Wisconsin state statutes currently only address fees for paper copies of records, and not the provision of electronic copies, you must look to Federal requirements. As outlined above, under 45 C.F.R. § 164.524(c), you may impose a reasonable, cost-based fee for electronic copies, provided that the fee includes only the cost of labor for copying the PHI and the cost of supplies for creating the electronic copy (such as the cost of a CD, USB drive, etc), the cost of postage if the copy is mailed, and the cost of preparing an explanation or summary of the PHI, if agreed to by the individual.
• Under HIPAA, a covered entity may charge individuals actual or average labor costs to fulfill a request for electronic (or paper) copies of protected health information that the covered entity maintains electronically. The labor cost must only relate to the cost of making copies, or creating a summary or explanation, if the individual has requested a summary and explanation.
291
292
9/20/2020
147
• For example, practitioners can charge the actual or average costs for photocopying paper, scanning paper into electronic format, converting electronic information into the format requested, transferring files (such as uploading or downloading) to a web-based portal, or creating or executing an email that is responsive to the request.
• If a covered entity does not wish to calculate actual or average labor costs associated with a request for health information in electronic format, the covered
entity may charge a flat fee of $6.50 for each request for electronic
records
• If HIPAA applies, covered entities should charge the lesser of: the charges applicable under state law or the charges applicable under HIPAA.
• As of March 2016, providers may not charge more than $26 for Workers Compensation records requested in electronic format. See 2015 Wis. Act 180.
YOUR FEE IS OUR FEE IS YOUR FEE
293
294
9/20/2020
148
Anti-Trust StatementPlease be advised that any discussion that leads to an agreement as to price
among competitors is a “per se” violation of the Sherman Act. Providers
gathered in any setting must always exercise caution and avoid discussions or
exchanges of information with their competitors on prices or pricing at
meetings since such discussions or information exchanges may give rise to
inferences of agreement.
Any agreement not to compete among business firms is also a “per se”
violation of the antitrust laws. Thus, no discussion of division of territories or
customers, or limitation on nature of business, should be held at any function.
Joint refusals to deal (boycotts), including discussions of blacklists, are likewise
unlawful “per se,” and no discussions related to these practices are permitted.
Discussion of fees by the WCA or Dr Chris Anderson or examples used are for
instructional purposes only and should not be considered a recommendation for any provider or group of providers.
Your Fee is your Fee!
• You must charge Everyone the same!• Exam (9920X Series) 300 Peanuts• Exam (9921X Series) 200 Peanuts• Adjustment (9894X Series) 100 Peanuts
• You Charge Everyone The same Price!
295
296
9/20/2020
149
Confused by Discounting Rules?
Definitions• Dual Fee Schedules
• Time-of-Service Discounts
• Improper Collection Policies
• Inducement Violations
• Anti-Kickback Statute Violations
• False Claims Act Violations
• Dangers of Free or Discounted Services
• Financial Hardship
297
298
9/20/2020
150
1Avoid Dual Fee Schedules
• Charging more to insurance companies than you do to cash patients:
• Illegal
• Misrepresents charges to carriers
• False Claims Act violation
• May violate provider agreements
• Triggers investigations
• Offering discounts that do not fall into one of Medicare’s safe harbors is absolutely a violation of federal regulations.
299
300
9/20/2020
151
2. Time-of-Service Discounts• Discounts to uninsured patients implicate the smallest body
of law as the federal rules and regulations governing Medicare and Medicaid patients are not triggered, and private insurance contracts do not directly control the uninsured-patient and provider relationship.
• That being said, providers offering discounts to uninsured prospective or current patients should proceed with
caution. Many private insurance contracts, as well as programs governing Medicare and Medicaid, have provisions commonly known as “Most Favored Nation” (“MFN”)clauses that may be triggered when discounts are offered to uninsured patients.
“Most Favored Nation” Clauses
• MFN clauses are generally used to describe an agreement between a buyer (insurer) and a seller (provider) that guarantees the buyer the best terms, including but not limited to the lowest price, for a product or service during the contract period.
• MFN clauses not only operate to guarantee that insurers receive the benefit of a bargained price between the provider and any additional insurers, but they may also apply to payments bargained for by an uninsured patient with a provider.
301
302
9/20/2020
152
• For example, assume that health insurer X negotiates a 50 peanuts with a chiropractor for an adjustment. A second insurer subsequently negotiates a 40 peanuts with the chiropractor for that same adjustment. Health insurer X, which contracted to charge 50 peanuts for an adjustment provided to a plan participant, may now charge 40 peanuts if a MFN clause exists in its contract
• The MFN clause operates to guarantee that an insurer’s members may benefit from the best terms available to any other patient, including uninsured patients.
• MFN clauses do not merely apply to prices negotiated by insurers, but also to charges for uninsured patients. To that end, if an insurer learns that a chiropractor is customarily charging $35.00 for the same adjustment to uninsured patients, the MFN clause may be triggered, and the insurer may have a right to only pay $35.00 fee, or the “usual and customary” $35.00 charge offered to the uninsured patient population.
303
304
9/20/2020
153
2. Time-of-Service Discounts
• Discount based on bookkeeping savings:
• 10-15%
• May not be permissible on Federally insured patients
• ChiroHealthUSA® (CHUSA) is a Discount Medical Plan Organization. CHUSA eliminates all the concern about which discounts are legal in which state, and how much is considered a “reasonable" discount by regulators. ChiroHealthUSA® allows you to select the discounted fee schedule that best serves your practice and patient’s needs. These discounted fees allow your patients and their dependents to save money on services not covered by their health insurance plan or for patients whom simply don’t have insurance.
• Basically, if you are giving more than a 5-15% discount (Per the OIG: Office of Inspector General, mandated by the government) from your actual fees you should stop doing that or use CHUSA in order to provide the discounts
legally. There's no fee for providers to belong to the CHUSA network. The
patients pay CHUSA a $49 enrollment fee, which covers their entire household for one year.
• It’s your hard earned money... don’t lose it to fines or penalties you can easily prevent.
• ChiroHealthUSA® will show you how, and it won’t cost you a dime! • Once you’re fined for an inducement or discount violation, there’s nothing you
can do except pay it or spend even more money fighting it. If your discounts trigger inducement violations, you can expect to pay up to $10,000 per occurrence. With fines like this, many practices are one inducement violation away from serious financial hardship, maybe even bankruptcy... Medicare, the OIG, and insurance companies ARE pursuing violators of State and Federal regulations.
• Offering discounts to your cash and underinsured patients can be legal if done properly!
• The solution is easy, free to set up, and recommended by the WCA!
Why not a different Discount Medical Organization? • CHUSA has one of the most flexible discount fee schedules on the market, unlike
other companies who may tell you what your discounts must be. • CHUSA offers the ability to set a family plan where you give additional discounts
to 2nd and subsequent family members. • CHUSA can be used with insured and Medicare/Federally insured patients for
their non-covered services.• Most patients recoup the membership fee on their very first visit. • CHUSA sponsors many free informative webinars and seminars throughout the
country to help our providers maintain a successful practice and keep up to date with the most current rules and regulations affecting your practice.
• CHUSA donates a portion of their proceeds in promoting the chiropractic profession.
• CHUSA donates to our State Association, the Congress of Chiropractic State Associations, the Foundation for Chiropractic Progress and the World Federation of Chiropractic.
• Heather Simmons• Phone: (888) 719-9990• Business Hours:
Monday – Friday 8:00 am – 4:30 pm CST
3. Inducement Violations
• Per the OIG: “incentives that are only nominal in value are NOT prohibited by [inducement law]
• No more than $15 per item, or $75 in the aggregate on an annual basis.
• Even one free examination, x-ray, or therapy is a risk
309
310
9/20/2020
156
Laws Against Fee-Splitting Arrangements
• State and federal laws prohibit providers from splitting revenue in exchange for referrals. See, e.g., Wis. Stat. § 446.04(4) (defining unprofessional conduct to include “[s]plitting or dividing any fee for chiropractic service with any person except an associate licensed chiropractor”).
• Most “voucher” discount sites such as Groupon or Living Social charge a percentage of the income generated on each “deal” that is sold. This sharing of income (between the provider and discount site) represents a portion of the fee that the provider would have received, and is likely in
violation of state and laws that prohibit fee-splitting
arrangements. Hence, discount programs offered by third parties that retain a portion of the fee charged may be unavailable as marketing opportunities by WCA’s members.
• A person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider, practitioner, or supplier of Medicare- or Medicaid-payable items or services may be liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act.
• The statute defines “remuneration” to include, without limitation, waivers of copayments and deductible amounts (or parts thereof) and transfers of items or services for free or for other than fair market value.
315
316
9/20/2020
159
Thanks you Notes
Mrs. Smith,
Thank you for referring Robert Anderson to our practice. One of the finest compliments a
practice can receive is the referral of friends and family. We appreciate your confidence, and we
assure you that we will care for Roberts health needs as we would our own family members.
Please enjoy the enclosed gift card for a free appointment as our way of saying an extra-special
“Thank you.”
I will not be able to see you any more as I violated Numerous laws and can be in prison.
317
318
9/20/2020
160
Anti-Kickback Statute• Applies to any form of remuneration to induce or
reward referrals for federal program business.• Money.• Free or discounted items or services (e.g., perks, gifts, space,
equipment, meals, insurance, trips, CME, etc..).• Overpayments or underpayments (e.g., not fair market value).• Payments for items or services that are not provided.• Payments for items or services that are not necessary.• Professional courtesies.• Waivers of copays or deductibles.• Low interest loans or subsidies.• Business opportunities that are not commercially reasonable.• “incentives that are only nominal in value are not prohibited by the
[Inducement Law]”• No more than $15 per item, or $75 in the aggregate on an annual
basis.• One free exam, x-ray or therapy is a risk
• Anything else of value…
Are Your Spinal Screening Tests Legal?Posted by: Mario Fucinari, DC, CCSP, MCS-P
• The Office of Inspector General (OIG) issued an advisory opinion (# 09-11) pertaining to free blood pressure screenings for beneficiaries participating in federally funded programs.
• The opinion may have an impact on how you conduct screening tests for the public, such as spinal screening tests.
• When an entity, such as a hospital, physician or an insurance company is unsure as to the legality of certain actions or arrangements, they may seek an advisory opinion from the OIG.
• In this instance, an advisory opinion was sought regarding the provision of free blood pressure screenings to walk-in visitors at a hospital. The hospital inquired whether the actions of their blood pressure screenings would constitute grounds for the imposition of sanctions under the civil monetary penalty provision prohibiting inducements to beneficiaries.
319
320
9/20/2020
161
• The anti-kickback statute makes it a criminal offense knowingly and willfully to offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Where remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the anti-kickback statute is violated.
• The statute attributes criminal liability to both parties involved in the kickback arrangement.
• For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind.
• For enforcement purposes, the OIG has deemed that services cannot exceed $15 per item of service or $75 in the aggregate annually.
• Under the actions involved in the advisory opinion, the hospital provided free blood pressure checks to visitors, some of whom are Medicare and Medicaid beneficiaries. The unnamed hospital did not indicate the fair market value of these screenings; however, the value of the multiple screenings could exceed $75, even if the value of single screening does not exceed $15.
321
322
9/20/2020
162
• For any type of free care offered by a provider, however, regardless of whether it is preventive care as defined in the regulation, it is necessary to determine whether the free care promotes the provision of other, non-preventive care reimbursed by Medicare or Medicaid.
• In this advisory opinion, the OIG based their opinion on whether providing the free service would induce a patient to obtain other services provided by that entity.
• As an example, if the hospital makes appointments for individuals with one of its physicians, offers individuals discounts for additional covered services, or otherwise promotes its particular programs, an inference may be drawn that the free screening test was an inducement to choose the hospital as a provider of other services.
• The screening tests would be permissible if the hospital provided an individual who tests positive for a chronic condition, with general information or literature and a recommendation that the individual contact his or her personal physician.
• Before taking part in any marketing or screening activities, it is advised that the physician obtain legal advice before proceeding.
• It is recommended that the policies pertaining to these screenings are well documented in a compliance manual.
• The OIG recommends a compliance manual for policies pertaining to Federal and state programs.
• This manual should not be confused with the HIPAA manual.
• If called into question the presence of a Compliance Manual will be used as a mitigating factor against further sanctions and fines.
323
324
9/20/2020
163
Thanks for Coming here is your free Bio freeze, your tee-shirt and water bottle
Facebook Slides
325
326
9/20/2020
164
Facebook Slides
Refer a patient Win a TV
327
328
9/20/2020
165
Did you Know…
• Ransomware has been the fastest growing cybercrime of the year. The FBI says cybercriminals could rake in almost $1 billion from these attacks in 2017 alone.
• Ransomware is quickly becoming the common cybercriminals favorite method of attack.
• That's because it is easy to mass deploy, payoffs can be massive, and with the use of Bitcoin as currency, payment exchanges can be virtually anonymous.
• Biggest way to get infected…Facebook.
If you think it’s not out there…
329
330
9/20/2020
166
Wisconsin
Advisory Opinions• OIG may issue advisory opinions.
• Listed on OIG fraud and abuse website, www.oig.hhs.gov/fraud.
• Not binding on anyone other than participants to the opinion.• But you are probably fairly safe if you act consistently with favorable
• The OIG has interpreted the prohibition to permit providers to offer beneficiaries inexpensive gifts (other than cash or cash equivalents) or services without violating the statute.
• For enforcement purposes, inexpensive gifts or services are those that have a retail value of not more than $15 individually, and no more than $75
333
334
9/20/2020
168
False Claims
335
336
9/20/2020
169
False Claims Act Violations
• Cannot knowingly submit a false claim for payment to the federal government.
• Waiving deductibles or co-payments and not reporting to carriers
• Up-coding for higher reimbursements
• Down-coding based on payer type
• Submitting claims for medical services not provided.
• Even a mistake…Need to have measures in place for checks and balances every 30 days
• These present “deliberate ignorance or reckless disregard of the truth related to the claim.”
• Must report and repay an overpayment within 60 days.
Spencer Chiropractor to Pay $62,349 to Resolve False Claims Act Allegations
• Elizabeth Kressin, D.C., from Spencer, Iowa, has agreed to pay $62,349 to resolve allegations she violated the False Claims Act by improperly billing the Medicaid system for medically unnecessary chiropractic procedures and for the treatment of conditions for which payment is not allowed, including bed wetting, colic and ear infections.
• The government alleged that Kressin caused the submission of the improper claims from January 1, 2008, through June 30, 2015. The claims settled by the agreement are allegations only; there has been no admission or judicial determination of liability.
May 1, 2018Kansas Chiropractor to Pay $1 Million-plus To Settle False Claim Allegations• KANSAS CITY, KAN. – A Kansas City area chiropractor has agreed to pay more than $1 million to
settle allegations his offices submitted false claims to Medicare for treating patients with peripheral neuropathy, U.S. Attorney Tom Beall said today.
• Brian Schnitta and his clinic, Natural Way Chiropractic Center, P.A., have agreed to pay the U.S. government $1,038,903 to settle allegations that they violated the federal False Claims Act. Schnitta owns and operates chiropractic offices in Overland Park and Lenexa, Kan., and in Lee’s Summit, Mo.
• The United States alleged that from July 1, 2011 through May 31, 2013, Schnitta and the clinic claimed they provided treatments for peripheral neuropathy and charged Medicare for several procedures that were not medically necessary or not otherwise covered by the program. The claimed procedures included nerve conduction tests, nerve block injections, and ultrasound needle guidance. Peripheral neuropathy affects nerves in the hands and feet and includes symptoms such loss of sensation and/or a burning sensation.
• A chiropractor may want to waive an insured patient’s co-payment, co-insurance or deductible due to financial hardship.
• In order to do so, the following conditions must be satisfied:
• (1) the chiropractor must receive and maintain written documentation of the patient’s financial hardship
• (2) the chiropractor must accurately report to the patient’s insurer the actual fee charged, if any, to the patient.
339
340
9/20/2020
171
Financial Hardship Waiver
• If the chiropractor waives all or a portion of the patient's copayments, coinsurance, or
deductibles due to the chiropractor, the chiropractor may not seek payment from the insurer for any portion of the copayment, coinsurance, or deductible waived by the
chiropractor unless the claim for the services related to the copayment, coinsurance, or deductible is reduced by an equal amount. Wis. Stat. § 446.02(10)(a). Notwithstanding the financial hardship exception, insurers impose a contractual duty on providers to make a reasonable effort to bill and collect the applicable co-pay and/or deductible.
• A provider’s failure to do so may result in a breach of contract claim.
What you need to remember regarding prompt pay and financial hardship discounts.
• Do not advertise any discounts.
• Offer prompt pay discounts only to patients who have not yet met their deductible or to self-pay patients (uninsured or insured patients receiving noncovered services).
• Do not discriminate in terms of which patients receive the prompt pay discounts (i.e., offer the discount to all patients unless a patient’s insurance contract prohibits it).
• Inform the third-party payer of a HDHP or insured self-pay patient of any discount offered and applied.
• Match the amount of the prompt pay discounts to the amount of money saved from collection costs.
• Do not offer prompt pay discount to reduce or eliminate a patient’s copayment or coinsurance amount.
• Check your insurance contracts to ensure there are no provisions that prohibit you from offering prompt pay discounts.
• Offer financial hardship discounts in accordance with objective guidelines.
• Apply financial hardship discounts uniformly to all patients who meet the objective guidelines.
• Be wary of offering frequent, large discounts that may adversely affect your “usual and customary” charge.
• When offering financial hardship discounts, reduce the amount owed by the insurer in proportion to the discount offered to the patient.
341
342
9/20/2020
172
Q:I have a patient who suffered from a headache and neck pain over the weekend. He called me at home and was subsequently seen on a Sunday. Is there any way of billing for treating a patient for an emergency Sunday visit?
• There is a CPT code used to code a visit that occurs on a Sunday, when a Sunday is a day that the office is normally closed.
• The code is 99050; it was revised in 2006. This code specifically is defined as "services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to the basic service."
• Therefore, for this visit you would code for the specific services done, such as examination, chiropractic spinal manipulation and any therapy, but you would additionally bill 99050 for the Sunday service.
• Note that most often, a "chiropractic emergency" visit is not one of a true emergency as defined in CPT, but a treatment wherein a patient is seen outside of regular hours.
• In this sense, to the treating chiropractor, it is of course an "emergency," but technically it is simply treatment outside of normal business hours or days, andwould be coded as above.
?
Q: How do I bill for a patient visit that I performed at the patient's home?
• To code for services done at a patient's home, the code is 99056. This code specifically is for "service(s) typically provided in the office, provided out of the office at request of the patient, in addition to the basic service."
• Treating someone at his or her home, you would use the code 99056.
• The use of this code would be in addition to the specific services done, such as examination and treatment.
• Additionally, on the CMS 1500 billing form, in block 24B ("place of
service"), you would indicate "12" which is the indicator for the
patient's home.
?
343
344
9/20/2020
173
Q: Is it ok to offer a referral coupon (excluding Medicare/Medicaid) to our
current patients to give family/friends that states that they will receive the initial consultation, examination and any necessary x-ray free of charge? Can we say free? Or does it have to be a discounted rate?
• The OIG states under section 1128A(a)(5) of the Social Security Act (the Act), enacted as part of Health Insurance Portability and Accountability Act of 1996 (HIPAA), that providers are prohibited to offer anything other than inexpensive gifts or services.
• For enforcement purposes, inexpensive gifts or services are those that have a retail value of no more than $15 individually, and no more than $75 in the aggregate annually per patient.
?
• Gifts and inducements come in many forms including: coupons or promotions for a reduced rate or free exams and x-rays, screening (spinal, blood pressure or foot scans), free dinners, movie passes, chances for a drawings for prizes for referrals and any other item or promotion that has a fair market value that is greater than
$15.00.
• Offering discounted or free examinations and x-rays could also place you out of compliance with other third parties contracts you have signed.
• It is important to read and understand the medical policies and contracts of any insurance company that you are a provider. When offering free or discounted x-rays it is important to make a statement that x-rays will only be provided if determined to be medically necessary so patients are not exposed to unnecessary radiation.
?
345
346
9/20/2020
174
• Offering gifts or cash for patient referrals or for patient visits would be an anti-kickback violation and against the state fee splitting statute in Wisconsin.
• The anti-kickback statute penalizes anyone who knowingly and willfully solicits, receives, offers or pays remuneration in cash or in kind to induce, or in return for referring an individual to a person for furnishing, or arranging for the furnishing, or any item or service.
?
347
348
9/20/2020
175
Are You Up to the Challenge?
• Earlier this year, the Office of Inspector General (OIG) took two critical steps that could impact your practice.
• First, they have asked for an additional $20 million to fight Medicare fraud, waste, and abuse. More money equals more audits.
• Second, they have introduced new and easier ways for patients to report concerns about pricing and discounts in provider offices ANONYMOUSLY.
• We reported earlier this year that the OIG is utilizing the impact of social media to educate patients on how to report pricing and discount concerns.
• With regular videos posted to social media and FB live events during which patients can #AskanInvestigator, the OIG is using every available channel to educate patients on identifying and reporting even their smallest concerns.
What is the difference?
• A "Good" discount is one that is compliant and may be applied to any patient no matter who is paying the bill. (Legally Defensible)
• A "Bad" discount is one that your state may allow, but not the feds or insurance carriers. (Subject to Interpretation)
• An "Illegal" discount is one that will likely land you in hot water if your office is audited. (Not Legally Defensible)
349
350
9/20/2020
176
• Whether you are an expert on discounting in your practice or not, test your knowledge in just 5 minutes and ten questions.
• Every correct answer gets you an entry in the challenge to win
$11,181!• Once you've answered a challenge question correctly, you will receive one prize
entry for that question. You can receive a maximum of 10 entries meaning you have answered all ten questions correctly.
• If you miss one of two, you’ll see information on what the correct answer should have been with links to sources where you can learn more.
• You may take the challenge as many times as you like until you answer all ten questions correctly.
351
352
9/20/2020
177
Question #1Which of these amounts represents the actual average fine for an OIG inducement violation?
• $11,181 is the average “per-occurrence” fine for Medicare
inducements violations per the OIG. That’s not $11,181 per patient,
that’s not per provider, that’s PER OCCURRENCE, which could be
Question #2Jerry is 73 years old. He slipped and fell in his garage. He received an exam, x-rays, adjustment, and therapy. Jerry was surprised that Medicare did not cover anything other than the adjustment. The chiropractor discounts Jerry’s total bill for the exam, x-rays, and therapy by 50%. Is this discount good, bad, or illegal?
• Illegal• Coupons, exam specials, or similar discounts should
not exceed $15 individually or $75 annually per patient.
Question #4Dr. Sarah has a habit of waiving the patient’s financial responsibility either in the form of a deductible, co-pay, or co-insurance. Is this discount good, bad, or illegal?
• Illegal!
• Under federal laws and most state laws, routinely waiving copays
raises potential violations of the Federal Anti-Kickback Statute,
Federal False Claims Act, and could constitute insurance fraud.
Federal plans and managed care plans are covered under federal
law, and most commercial plans, depending on the state, are covered
under state laws. If not illegal, it is most likely a violation of the
provider’s contract with the insurance carrier. Violating the contract
may result in the provider being removed from the insurance carrier
Question #5Dr. Smith decides to offer electrical stimulation to all his patients at no charge since most insurance companies do not cover it. Dr. Smith believes that this is a compliant discount for his patients because he is not charging anyone, including the insurance companies, for this service. Is this discount good, bad, or illegal?
• Illegal• Providing free services to patients is considered an inducement and is a
potential violation of the Anti-kickback Statute and the False Claims Act. In a recent case, a Chiropractor agreed to pay $79,919 to resolve allegations that he violated the False Claims Act by improperly billing Medicare for chiropractic adjustments after providing free electrical stimulation to beneficiaries to influence those beneficiaries to receive chiropractic adjustments in his practice. The government alleged that this conduct violated the Anti-Kickback Statute and, in turn, the False Claims Act.
Question #6Dr. Lee is out of network with UHC. Since he does not have a contract with UHC, he waives all co-pays for his UHC patients to make care more affordable for them. Is this discount good, bad, or illegal?
• Illegal!• Routine waiver of deductibles and copayments by charge-based providers,
practitioners or suppliers is unlawful because it results in (1) false claims, (2) violations of the anti-kickback statute, and (3) excessive utilization of items and services paid for by Medicare and other payers. Commercial health insurers have aggressively pursued out-of-network provides who fail to collect or waive amounts owed by their insureds under different statutory regulations.
Question #7Mary is a Medicare patient who recently hurt her back while gardening. Dr. Baker has recommended adjustments and therapy. Since therapy is not covered by Medicare, Dr. Baker asks Mary to join a Discount Medical Plan Organization (DMPO) so that he can offer her discounts on her non-covered services. Is this discount good, bad, or illegal?
• Good!• A discount medical plan organization is an entity that patients can
join in the doctors office. The DMPO, in exchange for fees, offers
access to contractual network discounts for its members to receive
discounts on medical or ancillary services under the discount medical
plan. Because consumer protection and health coverage is a
significant state concern, most have enacted laws specifically
regulating Health Discount Plans. Discount medical plan
organizations offer providers a compliant way to offer contractual
network discounts to their patients.• Source: https://www.ncsl.org/research/health/health-care-discount-plans-state-roles.aspx
Question #8The Office of Inspector General (OIG) has increased their funding to go after doctors for Medicare fraud, waste, and abuse. One of their tactics is to provide easier ways for patients to report concerns about pricing and discounts.
• True• Since 2017, the OIG has been utilizing Facebook and Twitter to educate
consumers on healthcare fraud, waste and abuse. A video posted in January 2019 included a mobile friendly link for viewers to click on to file a complaint
Question #9Dr. Jones wants to encourage more of her patients to bring in their children. She normally charges patients $50 for an adjustment. To make care more affordable, she only charges $25 per child up to age 16 when they get adjusted in the same visit with their parents. Is this discount good, bad, or illegal?• Illegal!• The Office of Inspector General has set a precedent by allowing a 5 to 15%
discount when services are paid upfront at the time of service. Since the provider's actual fee for the adjustment is $50, charging additional family members $25 (50%), clearly exceeds an acceptable time-of-service or prompt-pay discount.
Question #10Dr. Roswell practices in a state where time-of-service discounts can be as high as 25%. If Dr. Roswell chooses to offer the 25% prompt-pay discount that his state allows, is that discount good, bad, or illegal?
• Bad!• This discount is tricky. While it may be legal in your state, for instance North
Carolina, federal law trumps all state laws where discounts are concerned. In an OIG opinion, the recommended time-of-service discount range is 5%-15%. Dr. Roswell may find himself at risk if audited at a federal level (ie, Medicare patient discounts) rather than at the state level (ie, self-pay patient discounts.)
UPDATE!!!!Revised abn guidance for non par providers
• Medicare now requires non-participating providers to strike out the last sentence of Option 1 on the ABN & include the following highlighted statement in the (H) Additional Information Box:
• “This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”
UPDATE!!!!Revised abn guidance for non par providers
• Medicare now requires non-participating providers to strike out the last sentence of Option 1 on the ABN & include the following highlighted statement in the (H) Additional Information Box:
• “This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”
367
368
9/20/2020
185
369
370
9/20/2020
186
371
372
9/20/2020
187
• It should be noted that Medicare's stated reason for this change was to clarify the instructions for Option 1. They stated the following regarding the problem with conflicting information on an unassigned claim:
373
374
9/20/2020
188
• The last sentence of Option 1 states, “If Medicare does pay, you will refund any payments I made to you, less co-pay or deductibles.”
• This statement could be true for assigned claims. However, if the claim is submitted as unassigned and the claim is determined to be payable, Medicare makes payment directly to the beneficiary for the Medicare allowed amount as payment in full. Contrary to the highlighted statement above, a refund from the supplier to the beneficiary would not be required for an unassigned claim. The Centers for Medicare & Medicaid Services (CMS) has not received any comments or questions on the ABN as it applies to unassigned claims until recently when an industry representative asked for clarification. Although the current form instructions allow for insertion of any additional information, we would like to add instructions specific to non-participating suppliers and providers who are enrolled with Medicare.
• The official instructions state that "An ABN with the Option 1 sentence stricken must contain the CMS-approved unassigned claim statement as written above to be considered valid notice." Therefore, do NOT change the wording to say supplier/provider or provider in place of supplier. You must use the official wording for the ABN to be valid.
375
376
9/20/2020
189
377
378
9/20/2020
190
Purpose of ABN• Provide Medicare beneficiaries with advance
notification of their financial responsibility for any known or potentially non- covered services
• ABN indicates the reason (s) why it is likely that Medicare payment will be denied for that service (s).
• Non-covered services, as defined by Medicare, are never covered by Medicare and are patientsresponsibility to pay. Potentially non-covered services may or may not be covered by Medicare, depending on diagnosis used. So it requires a signed ABN.
General Rules• Patient’s/patient’s representative’s
signature must be obtained on the ABN which Medicare excludes due to medical necessity as defined by CMS
• ABN form must be signed prior to the services being rendered. (If it is signed after services or if a blank ABN is signed it is not valid)
379
380
9/20/2020
191
2 Sheets to UseParMed Sign 1X a Year Form ABN Form
2 Sheets to UseNonPar
Med Sign 1X a Year Form Non-par-ABN Form
381
382
9/20/2020
192
Suggestion
Med Sign 1X a Year Form
383
384
9/20/2020
193
Your Clinic NameYour Clinic AddressYour Clinic City State ZipYour Clinic Phone Number
Name as appears on Medicare Card
Name as appears on Medicare Card
385
386
9/20/2020
194
ABN Form
Clinic Name, Address, City State Zip and Phone #
387
388
9/20/2020
195
Maintenance World
389
390
9/20/2020
196
Clinic Name, Address, City Dstyate Zip and Phone #
Real Name Clinic # not SS
$
$
$
391
392
9/20/2020
197
Black or Blue Pen
ABN filing
• Original signed and dated ABN is filed in the clinic chart or if it is an EMR it should be stored in a retrievable fashion.
• A copy is to be provided to the patient.
• A copy is to be attached to the patient’s corresponding charge ticket (Super Bill) for charge entry purposes.
393
394
9/20/2020
198
Medicare Modifiers
It is Critical for every office to clearly understand the
proper use of Modifiers. Currently the only covered coded by Medicare are CMT Codes (98940,98941,and 98942) When they are “Medically Reasonable and Necessary”
395
396
9/20/2020
199
Medicare Modifiers
Here are the basics for coding and billing modifiers
NO Modifier Appended
When no Modifier is used, this indicates Maintenance care. Without appending an appropriate modifier, neither Medicare or the Patient would be responsible for payment of this Service.
Medicare Modifiers
Here are the basics for coding and billing
modifiers.
AT Modifier appended to Spinal CMT
Active Treatment for the corrective phase
of acute or chronic care. The Provider is
informing Medicare that this procedure
meets definition of medical necessity.
397
398
9/20/2020
200
Medicare Modifiers
Medicare Modifiers
GA Modifier appended to Spinal CMT
The Advance Beneficiary Notice (ABN) is the form that is used when a
covered service (spinal manipulation) is expected to be denied due to
lack of medical necessity. If the treatment of a Medicare beneficiary is
maintenance care, and therefore would be considered not medically
necessary and not reimbursable by Medicare, you would have the
patient sign an ABN and are required to append the GA modifier.
