What Are You Doing to Help Our Aging Population?
MEDICARE
By
Ray Foxworth
DC
The United States Census Bureau’s estimates project that 78 million people will be over the age of 65 by 2035, while 76.7 million will be 18 or younger. (Meola, 2019)
Although the rising cost of health care is a concern, so is the realization that we are facing a provider shortage in our country. The U.S. is expected to see a shortage of 46,900 to 121,900 physicians by 2032 in primary and specialty care, which creates an opportunity within the chiropractic profession to help our aging population. (Rogers, 2019) Are we up for the challenge?
Not many in our profession have a positive outlook when it comes to Medicare. Limits on covered services in chiropractic offices, coupled with increased audits, have many chiropractors just saying, “no.” In July 2009, the American Chiropractic Association (ACA) introduced a bill (H.R. 3654) that would align Medicare’s coverage of chiropractic services with that of other federal healthcare providers as well as many private health plans. (ACA, 2019) So, what does that mean exactly? According to the ACA website, if passed in its current form, the legislation would include, at a minimum, evaluation and management (E&M) codes, therapy codes (including but not limited to CMT codes), and certain diagnostic and X-ray codes. (ACA, 2019)
What about the increase in audits? The Office of Inspector General (OIG) has issued reports over the past several years that define critical issues related to chiropractic billing and documentation. In 2018, the OIG Work Report announced the highest rate of improper payment (from 2010 to 2015), ranging from 43.9 to 54.1% for chiropractic services, compared with 9.9 to 12.9% for all other Part B services. (OIG, 2018) As a result, we have seen a rise in audits. Part of the problem with chiropractic and Medicare has been that each Medicare administrative contractor (MAC) separately defined their interpretation of Medicare policy. This left 12 potentially different interpretations. Medicare sees this as a problem. “The good news,” said Dr. Scott Munsterman, an acknowledged expert on the transforming model of healthcare delivery, “is that work has been accomplished behind the scenes by Drs. Steve Conway and Michael Jacklitch, who worked one on one with chief medical directors of all of the Medicare contractors, to arrive at a consensus in how Medicare policy for chiropractic care should be interpreted and implemented.” Much of the expense involved with traveling to state association meetings to teach doctors the information on proper documentation was underwritten by ChiroHealthUSA.
Not many in our profession have a positive outlook when it comes to Medicare.
Having a universal interpretation puts everyone on the same page, and Medicare is now using this universal approach to teach chiropractors and “claims reviewers” alike. Without this universal approach, chiropractors could have seen policy decisions that substantially restricted care for Medicare patients, the largest growing population in our country. Steve Conway, DC, JD, stated that the most common request he receives from chiropractors across the country is, “Just tell me what to do.” However, he spends more time teaching them what not to do. Seem counterintuitive? “I find that many of us in the profession learn more from the mistakes of the past,” Conway says. And he’s right. As he and his good friends, Dr. Michael Jacklitch and Dr. Scott Munsterman, continue to share the universal interpretation of policy from Medicare across the country, we anticipate seeing improved error rates in the 2019 OIG report due to be released in March 2020.
Unfortunately, these changes cannot be forged by some without the help of everyone in the profession. Start by educating yourself and your team on the common mistakes made in Medicare documentation. Dr. Conway and Dr. Munsterman coauthored The Medicare Playbook with Dr. Tim Wakefield. In it, they provide a clear and concise explanation of Medicare’s policy and expectations. They also provide examples of what you should and shouldn’t be doing when it comes to your documentation. So, what are the most common mistakes?
1. Start-Over Diagnosis: There is a common misconception that if you change the diagnosis, then everything starts over and you can keep treating the patient. The OIG is concerned about this approach because it doesn’t match the “start, treat, and release” process of a true episode of care.
2. No End in Sight: The doctor keeps treating a patient two or three times a week. The patient has pain or other functional deficiencies that the doctor uses as evidence for treatment. With no end in sight, it merely looks like there is no treatment plan at all for the patients.
3. Keep Changing the Goal: Another misconception is, “If you just continue setting mini-goals, and reaching them, then you can keep treating the patient.” Again, there is no “episode of care” with a definitive beginning, middle, and end.
Maintenance-Only Approach: Unfortunately, some “expert” told chiropractors that the way to avoid billing Medicare altogether (and to collect directly from patients) is to have them sign an ABN form on the initial visit. Of all of the problems shared by Dr. Conway in his lectures, this one has the most serious consequences. The OIG views this practice as intentional fraud, and they are actively investigating these cases.
Amid the opioid crisis, chiropractic has been acknowledged as a solution for pain management by the medical community, thereby giving chiropractors the power to be paid for the broad range of services they provide for Medicare patients. (Lowry, 2019) There has never been a better time for improved legislation and broadening the covered services chiropractors provide Medicare patients. The ACA is asking chiropractors across the country to help by contacting their members of Congress and urging them to sponsor Bill H.R. 3654. The ACA has created resources, toolkits, and templates that are available for you to use in your communication with policymakers and the public. The ACA Government Relations team is available to help or answer any questions you may have. (ACA, 2019)
The chiropractic profession has been waiting over 100 years for an opportunity like this. We can’t continue to complain about limited coverage for the services that we provide if we are not willing to improve our documentation issues and don’t make an effort to speak up. It is time to stop pointing fingers and start helping our state and national associations by contacting lawmakers. Our patients and the future chiropractors of the profession are depending on us, a responsibility none of us can afford to take lightly.
Dr. Ray Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains "in the trenches" facing challenges with billing, coding, documentation and compliance. He has served as president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center, and is a Fellow of the International College of Chiropractic. To request a free one-page financial policy, send an email to info@chirohealthusa. com.
