Is Your Practice Guilty of Deflate-Gate

Is Your Practice Guilty of Deflate-Gate

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 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.  The following are just a few essentials of compliance that must be followed to avoid penalties and deflate-gate.

Proper Diagnosis Codes

On October 1, 2015, we are implementing 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 that you use the 17,000 codes available to you now.  In fact, the reason for the code expansion is that the codes will now become more specific.  Along with the specificity of the codes, if used properly, the codes will stop questionnaires from insurance companies.  You should make a list of your top utilized diagnosis 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.  The American Academy of Professional Coders has advised doctors to stockpile six months of cash because reimbursement will be delayed. If you start the conversion process now, you will not face delays.  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 and at www.ilchiro.org.

Proper Use of Modifiers

Modifiers communicate to the carrier that there is something different to be considered about the encounter.  Two of the most misused modifiers are the AT modifier in Medicare and 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.  In Medicare, the 59 modifier is used as a “last resort.”  Instead, it is now required to use the new XE, XS, XP and XU subsets for the -59 modifier in Medicare cases.  It is expected that other carriers will follow this regulation.  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 (Deflate-gate) may lead to penalties of $100,000 per scheme and the exclusion from participation in federal programs.  This is especially important if you order Durable Medical Equipment.

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 illegal to induce patients to come to you for care.

Just as a linebacker may not notice that the ball is deflated, your patients may not notice that your policies are not following regulations, but that does not make it right. “The chiropractor down the street never charged me for an exam,” 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. Just another example of “deflate-gate.”

Improper financial policies and collection procedures will not only decrease 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

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

Upcoming Courses

Dr. Fucinari will be presenting several classes and webinars to aid the doctor and staff in correct compliance procedures. For an updated schedule of classes and locations, go to www.ILchiro.org or 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

About Author

Mario Fucinari DC, CCSP, APMP, MCS-P, CPCO

Dr. Mario Fucinari has helped train doctors and staff over the last 20 years. He received his bachelor's degree from Wayne State University in Detroit and his Doctor of Chiropractic degree from Palmer College of Chiropractic in 1986. Dr. Fucinari was the recipient of the 1998 and the 2003 President's Award from the Illinois Chiropractic Society (ICS) for his work with education and training and most recently received the 2012 Chiropractor of the Year award from the ICS.

Dr. Fucinari was the first chiropractic physician to attain the Certified Medical Compliance degree. Two years later he earned his degree as a Certified Instructor for the Certified Medical Compliance Program. He is now the Chairman of the Chiropractic division of the national medical compliance program. He has produced classes and publications on HIPAA, Clinical Documentation, Medicare, and Stroke and Cervical Manipulation. He is a worldwide speaker for NCMIC, Foot Levelers, ChiroHealthUSA and several state associations and a Certified Chiropractic Sports Physician [CCSP].


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