Is Your Practice Guilty of Deflate-Gate?

Mario Fucinari DC, CCSP, MCS-P, MCS-I

Recent news reports have analyzed and bloviated about what is known as “deflate-gate.” It is alleged that the regulations were not followed pertaining to multiple game footballs that were underinflated in the AFC playoff game between the Indianapolis Colts and the New England Patriots. Even though one of the Indianapolis Colts linebackers said that he did not notice any difference in the ball upon his interception, it still is the contention that by not following the regulations, it cheapened the game and gave the Patriots an illegal edge. Many can say that some in practice may be guilty of “deflate-gate” by not following regulations, thus cheapening the quality of care they deliver and maybe even giving them an illegal edge.

The Patient Protection and Affordable Care Act (PPACA) of 2010 requires that providers adopt a compliance plan as a condition of Medicare enrollment. This is just the latest in laws, rules and regulations that ultimately will result in better patient care. Many providers object to the regulations and, without getting into the politics of the policies, they fail to see that these changes are ultimately for the benefit of the patient.

The Office of Inspector General (OIG) has given us compliance guidance for individual physicians and small groups. The OIG’s voluntary guidance is helpful in formulating a compliance plan to meet the requirements of the PPACA. Meanwhile, several chiropractic offices are seeing a deflation in their patient base, chiropractic coverage, reimbursement and income. The irony is that by following a compliance plan, you can actually increase patient outcomes and your income.

Proper Diagnosis Codes

On October 1, 2015, we are going to the ICD-10 classification of diagnosis codes. 17,000 ICD-9 codes will now expand to 68,000 ICD-10 codes. While the expansion may seem daunting, you will no more use 68,000 codes than you use the 17,000 codes available to you now. In fact, the reason for the code expansion is because the codes will now become more specific. Along with the specificity of the codes, if used properly, the codes will stop questionnaires if used properly. You should make a list of your top utilized codes, a personal “Playlist” if you will, and convert them to ICD-10. Make sure you code completely within rules and regulations and prepare ahead of time. There are several classes and books available, including books that I have authored and classes presented throughout the United States. More information is available at www.Askmario.com.

Proper Use of Modifiers

Modifiers communicate to the carrier that there is something different about the encounter to be considered. Some of the most misused modifiers are the use of the AT modifier in Medicare and the use of the -59 modifier in all other cases. The -59 modifier may have to be used when applicable if Neuromuscular Education (97112), Massage (97124) or Manual Manipulation (97140) is used when also providing manipulation services. In fact, the -59 modifier for distinct procedural services is so misused that CMS released new codes and guidance on January 5, 2015 to use the new XE, XS, XP and XU subsets of the -59 modifier. The clarification is not to cut reimbursement, but rather to reimburse for properly documented, medically necessary care.

Stark Law

The Stark Law was released in three phases (1998, 2004, and 2007.) The Stark Law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. If a physician or a family member has a financial relationship with an entity, the physician is prohibited from making a referral to the entity for designated health services for which the Medicare or Medicaid programs would otherwise pay. Your state may also have similar laws and regulations, so you should consult with an attorney if this affects you. Violations of the Stark Law may lead to civil money penalties of $15,000. Schemes to get around the Stark Law may lead to penalties of $100,000 per scheme and the exclusion from participation in federal programs.

Anti-Kickback Statute

Under the Anti-Kickback Statute, it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value (remuneration) in return for a referral, or to induce generation of business reimbursable under a federal health program. There are also many states that have enacted laws that prohibit payment for referrals. Under the anti-kickback statute, it is also illegal to induce patients to come to you for care. They may not even notice that your policies are not following regulations, but that does not make it right. This includes such inducements as routinely waiving coinsurance or deductible amounts without a good faith determination that the patient is in financial need, or failing to make a reasonable effort to collect the co-insurance and deductibles. Violations of the anti-kickback statute may lead to a fine of up to $25,000, imprisonment of up to five years, and the exclusion from participation in federal programs.

Improper financial policies and collection procedures will not only decrease your income, but may put you in legal predicaments. Rather than putting your career, your office and your license in jeopardy, ethical and compliant policies and procedures will improve your income legally. Discount plans such as ChiroHealthUSA will give you peace of mind and an opportunity to provide care for your patients at a legal, reasonable price. Without such policies and procedures, you will not be around to give your patients the care they deserve.

For a limited time, receive a copy of “Seven Steps to a Compliant Practice” by Mario Fucinari DC, MCS-P. Send your request to info@askmario.com and put CHUSA Compliant Procedures in the subject line. Personal e-mail questions cannot be handled at this automated request address. See below for further information.

Dr. Fucinari will be presenting several classes and webinars to aid doctors and staff in correct compliance procedures. For an updated schedule of classes and locations, go to www.AskMario.com. Dr. Fucinari is the author of several books, including, ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office, available at www.Askmario.com. Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. For further information on chart audits, compliance audits, manuals or consulting, please contact Dr. Fucinari at Doc@Askmario.com.