Tell ITLike ITIs Medically Necessary or Clinically Appropriate or Both Wait, What Is IT. What Was OIG s Objective? What Did OIG Find?

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1 Tell ITLike ITIs Medically Necessary or Clinically Appropriate or Both Wait, What Is IT Why Do We Need To Do Anything Different? OIG Reports on Inappropriate Medicare Payments for Chiropractic Services On May 6, 2009, the Department of Health and Human Services' Office of Inspector General(OIG) OIG examined 2006 chiropractic claims for beneficiaries receiving more than 12 services from the same chiropractor. What Was OIG s Objective? Such services were appropriate. Controls ensured that chiropractic claims were not for maintenance therapy. Claims data can be used to identify maintenance therapy. Chiropractic claims were documented as required. What Did OIG Find? Medicare inappropriately paid $178 million representing 47 percent of claims Efforts to stop payments for maintenance therapy have been largely ineffective. Claims data lacks initial visit dates for treatment episodes, hindering the identification of maintenance therapy. Chiropractors often do not comply with the Medicare Benefit Policy Manual documentation requirements What Did OIG Recommend CMS Do? Implement and enforce policies to prevent future payments for maintenance therapy. Review treatment episodes rather than individual chiropractic claims Ensure that chiropractic claims are not paid unless documentation requirements are met. Take appropriate action regarding the undocumented, medically unnecessary, and miscoded claims identified in the OIG's sample. Makes no Bones About it, They Are After Us and it is off with our heads. 1

2 I Know I Need to Change But, How Do I Do It? 5 Tell IT Like IT Is-Languages Know what IT is & what IT isn t. Know how to properly document IT. Make sure your entire Team speaks IT. Know how to discuss IT with your patients. Know how to properly manage IT. IT = Medical Necessity Know What ITis And What ITIsn t IT= Medical Necessity The patient must have a significant health problemin the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationshipto the patient s condition and provide reasonable expectation of recovery or improvement of FUNCTION. IT=This is Active Care What IT Isn t Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. Don t Get Confused: Just Because It Isn t Medically Necessary Doesn t Mean It Isn t Clinically Appropriate. Think of IT Like This Meet Ethel These are 2 different things Medically Necessary by Insurance Definition relates to functional improvement Does a subluxation need adjusted even though it is not causing a functional limitation? YES that is Clinically Appropriate. 2

3 Ethel Starts Her Treatment Episode But What Do We See No Functional Improvement No Functional Improvement Who Should be Paying What? Functionally Improving Stop Care Start Care Medically Necessary Yes, Insurance Maintenance: Yes, The Patient One Big Problem Though But, we ve been training them for years..they come in when they have pain, we bill their insurance, and continue to do so until they stop paying. We ve been iffy about collecting co-pays and deductibles etc. 3

4 Entire Team Should Speak the Language Front Desk Responsibility Know when patients are in a treatment course Screen calls for new condition Know when a new course begins Schedule patient appropriately Have scripting in place Doctor Responsibility Discuss with existing patients Be clear with all new patients Understand Case Management Paperwork for collecting ADL information Telling IT Like It Is -Nicely New Patient/ROF ROP Patients in a current Treatment Episode Medicare Patients (especially those receiving services free of charge) Those pop in patients that just want a pop New Patient Consult Function means your ability to.. We will not only be asking about your pain, but Function Give exact examples: Pain only with NO functional limitation= 0 Coverage It means, they will only pay for treatment that will improve your function. Report Of Findings Report Findings Lay Out Entire Treatment Plan Explain importance of the re-exam Introduce Maintenance Care Prepare Them To Pay When Visits Are Maintenance Help them to identify Medical Necessity Patient In a Treatment Episode What I ve learned I don t want What WE need to do Explain Medically Necessity Again, introduce paying for Maintenance Pain but no limitations Want one adjustment Want you to bill insurance They direct you on how to treat them. Do this time and time again. Pop In Patient 4

5 Remember Each time you send in a claim for something that is not Medically Necessary, you are taking on liability PoP In Scripting.. Changes Explain Medical Necessity Best way to handle today s Maintenance visit. Introduce CHUSA Let the patient decide. Front Desk With Existing Patients Be prepared for these Pop in patients. When was the last time you saw the Dr.? I just need a good ole cracking Practice your scripting Introduce the concept of change Schedule them Medicare Patient Changes Medicare s definition of Medical Necessity. Medicare s definition of Maintenance Therapy What we have been doing What we will be doing Be Prepared Visual Aids Have paperwork in place that will help you gather ADL s. Use at NP intake, re-exams and ROP Review the appointment book daily making note of patients to be advised of change Practice scripting with entire team so all members are speaking the same language Have a legal discounted fee program Dry Erase Boards-can draw out the active and maintenance care Laminate Medicare definitions of Active Care and Maintenance Care Have copies of these definitions for them to take home 5

6 Review every morning and note patients that need advised. Ensure any ROP patient is scheduled for a reexam Every patient in a Treatment Episode must have periodic reexams to prove medical necessity. Appointment Book Paperwork Examples: Oswestry Quad VAS Neck Index Back Index Etc. Legal Cash Discount Program KMC Recommends ChiroHealthUSA Attitude Have a positive attitude Don t look at this as a bad thing. No more worries about a request for chart reviews from 3 rd party payers. Put the financial responsibility where it belongs Manage IT Make up your mind then do it Access your current paper work and add ADL s or functional assessment forms if needed Notify all patients about the changes..one by one. Look at your appointment book daily and identify patients Act out the scripting and training with your team member. Get a compliant discount payment plan - CHUSA Evaluate your treatment plans 6