How to Save $694,887
RISK MANAGEMENT
Kathy Mills Chang
At the end of 2014, Henry Chen, MD, and his group practice, Jennan Comprehensive Medical, settled with the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) to the tune of almost $700,000. Dr. Chen and his partners were tripped up by their physical therapy service claims submitted to Medicare. Although they are medical doctors, any one of their documentation and compliance errors could easily have been committed by a doctor of chiropractic. The four things they did “wrong” are all items many DCs overlook on a regular basis. Let’s look at what happened and what you can do to avoid it:
• The OIG alleged that the doctors’ physical therapy services weren’t carried out or supervised by the rendering provider. Insurance carriers (and Medicare, in this case) require that medical doctors and chiropractors carry out active care and PT services with very specific procedures and processes in order to be billable. Thirdparty requirements may or may not agree, by the way, with the laws in your state about supervision of services; in fact, they’re often more stringent. The lesson here is to check your contracts with all of your carriers to find out their rules about billing for services supervised by someone other than the doctor. Also, double-check your state’s guidelines and leam the difference. State law may allow for others to supervise services, but if it doesn’t fly with the carriers with whom you signed contracts, the carrier or OIG can—and in this case did—nail the practice. Bottom line: know who is allowed to supervise or provide services you bill out under the provider’s name.
• Group services were billed as one-on-one providerpatient physical therapy services. Constant attendance modalities and therapeutic procedures, such as exercise, require one-on-one attendance by the provider of care. That means that if there’s one provider or assistant and three patients exercising in the back room, one-on-one care is impossible to provide, as Dr. Chen found out to his detriment. Often, audits uncover this by checking appointment schedules against employee logs for the day to see whether one-on-one attendance was even possible given the number of patients seen versus the number of employees on staff that day. We think you’re always better off having two or three additional people to keep your rehab moving, rather than limiting yourself (and your reimbursements) to one patient every 15 minutes. You’re certainly better off bringing on part-time staff than risking this kind of deep gouge from the OIG or a carrier for skirting the mies. Bottom line: know what your contracts say about one-on-one attendance
versus group therapy and bill it correctly and compliantly.
• Services were performed by unqualified individuals. It’s hard to say what type of assistant was inappropriately providing services in Dr. Chen’s practice. What we do know is that chiropractic assistants are not licensed, registered, or certified in most states to provide rehab services (Florida and Tennessee are two exceptions). So even if you have a trusted and properly trained CA holding a cold laser on a patient, from a legal standpoint, your carrier may not permit it. Again, this comes back to checking with your state to see to whom you aie legally allowed to delegate, and then looking at your carrier contracts to see what you’ve agreed to. For example, a certain Blue Cross and Blue Shield policy says that only MDs, DOs, and LMTs may provide muscle work or rehab. That’s why many savvy DCs we know hire an LMT just to supervise rehab. Bottom line: have proper compliance policy and procedures in place that outline how you comply with state and carrier regulations for delegation of services.
• Claims for time-based physical therapy services did not accurately reflect the actual time spent performing the services. Timed therapy coding and tracking is a huge area of confusi on for many chiropractors. Medicare’s eight-minute mle means that if y ou aie performing only one constant attendance modality or procedure, you must do it for at least eight minutes in order to bill for that service.
To make things more complicated, if you perform multiple timed procedures, you must correctly add the resulting “units” and calculate the charge. It’s the difference between single-service timed codes and multiple timed codes, and it trips many DCs up. Of course, we must also consider that DCs aie “supposed” to follow the CPT rules of 15 minutes per unit, yet, that is also largely left up to interpretation. Bottom line: set proper policy and procedures about how you count and document time for time-based CPT codes, record time in your patient’s medical record per procedure, and bill accordingly.
Kathy Mills Chang is a Certified Medical Compliance ■ I Specialist (MCS-P) and, since 1983, has been providing ni J2 chiropractors with reimbursement and compliance train^ ing, ad\’ice and tools to improve the financialperformance of their practices. Kathy is blown as one of our profession ’s foremost experts on Medicare and can be reached at (855) TEAMKMC or info afimeuniversity. com
