Chiropractic CA 101. Instructor : Sue Ware, MCSP

Transcription

1 Chiropractic CA 101 Instructor : Sue Ware, MCSP

2 Sue Ware, MCS-P Board Certified Medical Compliance Consultant & Billing Specialist Specializing in Chiropractic I have Owned and Worked in Chiropractic Offices for 25 Years in 3 different states April 2012, Medical Compliance Specialist- Physician Certification Program (Specializing in Chiropractic) Dr. Mario Fucinari, D.C., CCSP, DAAPM, MCS-P Instructor *Meeting the Continuing Education Requirements each year for MCS-P

3 Continuing Education 2012 Insurance Consultant Program for Chiropractors at Logan University I was the only non-doctor attending this program. This program provided me advanced training in * Billing procedures in Medicare, WC, PI, and Commercial Insurances. * Compliance * Meaningful Use * Documentation Requirements * Chart Audits * PQRS * Medical Necessary Documentation Auditing and Evaluating Chiropractic Offices. Various Hipaa Seminars CA Program at Logan University, Attended and received a certificate of completion Through the last 25 years I have attended numerous Seminars and Webinars on All Chiropractic Topics

4 I am a self taught expert in the Chiropractic Field. 25 years ago, I opened my husband s practice with no previous medical healthcare experience. I have worked every position in the office Office Manager, Front Desk CA Insurance, NF, WC, PI Billing Specialist Back Office CA Assisting doctor taking notes Patient Vital Signs Organizing Offices Creating Forms Auditing Accounts Hiring Staff

5 My Experience includes: Consultant to New Chiropractors Evaluation & Consulting of Established Offices Assisting New Chiropractors in setting up an office Training Office Staff Provider Credentialing Creating Individualized Office Policy Manuals

6 Topics for Today s Seminar Understanding Chiropractic Office Staff and Departments Responsibilities of all departments Chiropractic Terminology Billing Procedures Spinal Regions CPT Coding Necessary Documentation umentation

7 CMS 1500 Form Medicare Active and Maintenance Care ABN Form Billing Procedures Documentation PQRS

8 Policies and Procedures Manuals Office Policy & Procedure Employee Compliance Policy & Procedure HIPAA Educating Doctors and Staff Provider Credentialing with Insurance Carriers

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10 Innate Intelligence (Big Idea) Chiropractic is founded on this concept, which is that the body heals itself when interference to the proper functioning of the nervous system is removed

11 The Practice of Chiropractic Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches.

12 Doctors of Chiropractic often referred to as chiropractors or chiropractic physicians practice a drug-free, hands-on approach to health care that includes patient examination, diagnosis and treatment. Chiropractors have broad diagnostic skills and are also trained to recommend therapeutic and rehabilitative exercises, as well as to provide nutritional, dietary and lifestyle counseling.

13 ALL EMPLOYEES should Know How Chiropractic Works When you need to answer questions or explain to patients. KEEP IT SIMPLE ** Spinal Manipulation is the technique the doctor uses to correct Subluxations to Align the Spine to Allow the Nervous System to Work ** Subluxations are caused by our inability to handle life s four major stresses: Physical Mental Emotional Chemical ** Left untreated subluxations have devastating effects upon human health and well being. Leading to Breakdown, Malfunction and Disease.

14 The Patient is assured that the office staff handling their scheduling and financial part of their treatment properly. If you are confident and knowledgeable you are able to convey all information needed to the patients in a calm, intelligent and compassionate way. With your knowledge and experience, how would you respond to the question, Could the Chiropractor fix me?

15 The Chiropractic Office The Staff The Departments

16 Departments in a Chiropractic Office Front Office, Back Office, Billing Staff, There could also be a separate Management Department Depending on the size of the office that could be ONE EMPLOYEE. This is very possible, you just have to be very organized, dedicated, knowledgeable, self motivated and love your job. All your responsibilities will be accomplished. Sometimes having more employees is NOT always an Asset. If everyone doesn t know or do their responsibilities, then tasks are not always completed. Staff members may think someone is doing the task, but in reality nobody is.

17 Chiropractic Assistants are POWERFUL EMPLOYEES CA s are have a lot of influence on the practice. There is only one chance to make a 1 st Impression and the CA is that person in a Chiropractic office. CA s often spend as much or more time with patients than the doctor. CA s become an extra set of eyes and ears for the doctor. All CA s should Know, Understand, and Believe in the Practice of Chiropractic. CA s communicate, educate and are empowered with the knowledge of the chiropractic language, the philosophy, and the practice of chiropractic. Each Chiropractor has a different philosophy, if you don t know your chiropractor s, you should ask what your doctors philosophy is.

18 CA s LIST OF TASKS IN THE OFFICE All Departments Focus on the outcome of Chiropractic Care Patient Receiving the Best Possible Care Opening and Closing the Office Answering the phones Scheduling patients Insurance verification Appointment confirmation calls Missed appointment calls Processing of New Patients, paperwork, explaining benefits, their responsibilities and your office polices for their 1 st visit Data entry: Patient demographics, charges & payments Obtaining required referrals or authorizations Completing Paperwork for Approval of Treatment Obtaining X-ray, MRI, CT films or reports Patient Flow: Patient Care: vitals Patient billing Collections Insurance billing Data entry of insurance payments Follow up on Accounts Outstanding Account audits Filing Scanning Records request AND MORE..

19 Focus on the OUTCOME of Chiropractic Care Its is like throwing a life Saver How do Patients get to a POSITIVE OUTCOME? Friendly and Personal Greeting by employees either by phone or office Scheduling patients to fit their needs into your office schedule Giving the Best Chiropractic Treatment to all patients Help stressed out patients to understand their financial responsibilities for their road to recovery with chiropractic care We are not responsible on how and why patients come to the office, but we are responsible on how they leave

20 Answering the Phone and/or Greeting the Patient FRONT DESK CHIROPRACTIC ASSISTANT The Front Office CA sets the initial tone of the patient s experience. You do not get a second chance to make a first impression. Calling or Walking into a Chiropractic office can be uncomfortable or even scary for patients. Always create a positive impression with New or Established patients. Make them feel they have your undivided attention. Patients need to feel like they have been heard, acknowledged and that all their questions have been answered.

21 Answering the phone - Basics Always SMILE when you answer the phone Follow your Phone Scrips Phone Scrips allow you to give proper and consistent information to all patients by all employees Inform patients of our office procedures. Potential Patient Forms Use them to obtain all information needed to schedule and be prepared for the visit. Create File Folders, verify benefits and whatever else your office needs for 1 st visit.

22 Choose your words carefully Patients may comment if the waiting room is full, are the doctors running behind? You are right the doctors are helping a lot of people today Other patients are in need of the great care we give our patients The doctor has had a couple emergencies today that had to be squeezed in Making Recalls for missed appointments When making the calls, you should always be in the right frame of mind. Call 15 minutes after missed appointment. Not scolding them, you are showing concern (are they ok) Want them to stay on track with the doctor s recommended treatment plan. Phone Scrips Say I understand don t say That s okay (that is giving them permission to do it again) If you leave a message: We didn t get the pleasure of seeing you today. if your schedule permits it just tell them come in later if you can, just walk in, if not I rescheduled you for same time on (day) or next week, if that is not ok please call the office. Document the recall and the result of the phone call.

23 FRONT and BACK OFFICE CHIROPRACTIC ASSISTANT Acknowledge the patient greet with a smile or a hand shake if possible Never ask the patient How are you today? You can ask your Doctor, but we never ask this question. Patients tend to tell you a detailed description of their condition and then when they go into the adjusting room, they almost feel they have already said it and the doctor seems to gets a shortened version. So not all the necessary information is documented into the daily note. Other choices of greeting the patient: I am glad you are here today It s great to see you, its been awhile How are your family members? How is your new job?

24 Question you can ask a Patient Some patients are more concerned with the financial aspect of their care than the result of their care. No, you don t want to put financial burden on a patient but you do want them to continue care when needed to achieve the full benefit of Chiropractic Care. Incorporate a question into your Intake form New Patient Benefit Explanation Talk Establish Patient Who becomes hesitant about continuing care If this Condition Was Gone, What Would Be the First Thing You Would Do? Cost Doesn t Matter to Be Well, and Do the Things That are Important To You

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26 What ever your position is in a Chiropractic office, it is vital that you use, know, and understand how to Speak Chiropractic Subluxation: change in the structural or functional dynamics of a joint. Primarily in the spine. Exacerbation: to increase the severity, to aggravate an existing condition. Vertebra: A bony segment of the spine that encircles and helps protect the spinal cord and nerves. Musculoskeletal: Referring to structures involving tendons, muscles, ligaments, and joints.

27 Intervertebral disc: Tough cartilage that acts as a cushion between two vertebrae. Each disc has a gelatinous-like center. When it protrudes, it is called a Disc Herniation. Spinal Manipulation: is the main chiropractic treatment technique, type of manual therapy, also called chiropractic adjustment. The purpose of manipulation is to restore joint mobility by manually applying a controlled force into joints that have become hypomobil or restricted in their movement as a result of a tissue injury. Cavitation: A POP that happens in a spinal joint when the vertebra are separated by manual adjustment to create a vacuum that pulls in nitrogen gas.

28 Assignment of Benefits: (AOB) An arrangement by which a patient requests that their health benefit payments be made directly to the doctor. Allowable Amount: the maximum dollar amount that a third party, usually an insurance company, will reimburse a provider for a specific service. Deductible: a specified amount of money that the insured must pay before an insurance company will pay a claim. Copay: fixed amount paid by the patient each visit with insurance picking up the remainder. Co-Insurance: a percentage the patient is responsible to pay for each visit. Stop Loss: policy is a policy that takes effect after a certain amount has been paid in claims. Companies providing health insurance for their employees through a self-insured plan often subscribe to stop loss policies in order to protect themselves against catastrophic claims.

29 Chiropractic uses Acronyms DC: Doctor of Chiropractic CA: Chiropractic Assistant CMT - Chiropractic Manipulative Treatment also referred to as SMT Spinal Manipulative Treatment DX: Diagnosis TX: Treatment ROF: Clinical Report of Findings (doctor explains to the patient his or her clinical findings of the patient s condition and makes treatment recommendations, usually on the 1 st or 2 nd visit)

30 MVA: Motor Vehicle Accident PI: Personal Injury Case (some states call Auto injury cases PI) NF: Auto Injury Case WC: Worker s Compensation Injury Case DOI or DOA: Date of Injury or Date of Onset DOS: Date of Service

31 EHR: Electronic Health Records EFT: Electronic Funds Transfer ICD: International Classification of Diseases. These codes describe the patient s diagnosis. Currently ICD-9 codes eff: 10/1/15 IDC-10 codes CPT: Current Procedural Terminology ABN: Fee For Service Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, is issued by providers to patient in situations where Maintenance care for a Medicare payment is expected to be denied. ADL: Activities of Daily Living OATS: Outcome Assessment Tools PHI: Private Healthcare Information

32 DMPO: Discount Medical Plan Organization is an organization that allows chiropractors to set legal discounted fees. (Chiro Health USA). OIG: Office of Inspector General CMS: Centers of Medicare and Medicaid Services HHS: Health and Human Services

33 Most Common Unknown or Ignored Laws Hardship agreement: financial determination established in advance in your procedures and policy manual when a patient is unable to pay the actual fees established by your practice. This policy must be applied consistently across the entire patient roster. There are requirements to meet and documentation to have on file for each hardship agreement. Inducement: Offering illegal freebies, gifts, or discounts. Legal discounts are allowed to be of $10 per patient not more than five times per year.

34 Dual Fee Schedule: Charging a different fee for same CPT code, depending on the insurance carrier. Charging cash patient less than insured patient can also be called a dual fee schedule. Time of service discounts may apply to this. No Out Of Pocket Expense: (NOPE) Not collecting deductibles, copays, coinsurances from patients according to patient s insurance benefits. Time of Service Discounts: (TOS) offered to patients who are able to pay on the spot. In order to abide by the Office of Inspector General(OIG) guidelines suggests these discounts fall between 5 to 15% of the actual fee charged for such service.

35 Stark law: is a limitation on certain physician referrals. It prohibits the provider referrals to designated health services (DHS) such ahs DME companies for Medicare and Medicaid patients if the provider has a financial relationship with the entity. A financial relationship includes ownership, investment interest, and compensation arrangements. Anti-Kickback Statute: is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business (Medicare/Medicaid). The Anti-Kickback Statute is broadly drafted and establishes penalties for individuals and entities on both sides of the prohibited transaction

36 Difference between EOB and Remittance Advice An explanation of benefits (EOB) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. The EOB is commonly attached to a check or statement of electronic payment. The major difference between a Remittance Advice and an explanation of benefits is in who receives the statements. Both types of statements provide an explanation of benefits, but the remittance advice is provided directly to the health-care provider, whereas the explanation of benefits statement is sent to insured patient. Although this is almost always the case, the health insurance provider will, on occasion, send the health-care provider the explanation of benefits instead. Some Remittance Advice s are called Explanation of Review (EOR).

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38 The Treatment of the Spine, with Spinal Manipulation There are 5 Regions of the spine Cervical (7 vertebrae) Thoracic (12 vertebrae) Lumbar ( 5 vertebrae) Sacrum Coccyx

39 CPT codes for Billing Spinal Manipulation Manipulation of the Spine 1 2 Regions Manipulation of the Spine 3 4 Regions Manipulation of the Spine 5 Regions Medicare Billing for Manipulation of the Spine 98940, or AT modifier Active or Acute Care 98940, 98941, or GA modifier Maintenance Care

40 E / M Services - Evaluation and Management Examinations for New and Establish Patients Exams Re-exams Exacerbations Release / Discharge From Active Care Consultations Report of Findings (ROF) also called Counseling Consultations

41 Rules and Requirements for E/M Code Billing The E/M Documentation Guidelines were developed in 1995 & 1997 You can choice which guidelines to follow, but you must stay within those guidelines and meet the requirements to bill the CPT code for E/M Services Key Components Patient History Examinations Clinical Decision Making Contributory Components Counseling Coordination of Care Nature of Presenting Problem Other Component Time

42 CPT Coding for E / M Billing Examinations CPT codes range from for New Patients CPT codes range from for Established Patients Consultations CPT codes range from for Both New and Established Patients

43 E/M and Spinal Manipulation Performed on Same Visit When E/M services are significant and separately identifiable and the CMT is preformed on the same visit the 25 Modifier should be applied to the appropriate E/M code.

44 Modifier 25 Example: Expanded Problem Focused New Patient Examination Spinal Manipulation (3-4 regions) Example: New or Established Consultation Spinal Manipulation (1-2 regions)

45 CPT Coding for Therapeutic Procedures Hot or Cold Packs Mechanical Traction Electrical Stimulation Massage Manual Therapy / Soft Tissue Mobilization Cold Laser Therapy S9090 Spinal Decompression

46 Modifier 59 on the CPT Code Have you been DENIED for the use of this CPT Code? The Guidelines state that services are included in the CMT codes ( ) when performed on the same spinal region If you bill service it has to performed to a different region of the spine than what was adjusted.

47 The Key is Where the Muscle attaches to the Spine If Lumbar is adjusted, the doctor can not perform Soft Tissue Mobilization to any muscle that attaches to the Lumbar Spine. Example: CMT to Lumbar spine Soft tissue Mobilization to Hamstring

48 Documentation Tips for Physical Medicine Procedures When billing for all physical medicine procedures, such as there are 3 things that should be documented: Technique (manual traction soft tissue mobilization) Location ( cervical spine, lumbar spine, what muscle or group of muscles) Time (clock time 2:00pm to 2:08, not just 8 minutes)

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50 Eff: 4/1/2014 the CMS Form (02/12) Replaced the CMS 1500 Form (08/05) The instructions can be found at the National Uniform Claim Committee (NUCC) website

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52 M E D I C A R E Chiropractors can not OPT OUT OF MEDICARE If any Doctor Treats a Medicare Patient they have to be registered with Medicare The Doctor can NOT Treat the Medicare Patient for an active or acute condition, charge the patient cash and NOT Bill Medicare Even when a doctor treats a Medicare Patient for Maintenance condition, completes the ABN form Not to bill Medicare, the doctor still has to be registered with Medicare The doctor can either be Participating (PAR) or Non- Participating Providers (Non-PAR)

53 Participating Provider - Provider has signed an agreement to participate with Medicare. Required to accept assignment on every patient. Every Patient has a $147 yearly deductible. Will Follow Allowable Amount Fee Schedule. Waits for payment from Medicare and secondary carrier. Medicare pays 80% of allowable fee schedule. Patient s secondary insurance or if none, patient would pay the 20% coinsurance.

54 Non-Participating Provider Provider has not signed an agreement to participate with Medicare. Every Patient has a $147 yearly deductible. Can accept or not accept assignment for Medicare patients. Assignment accepted: Providers would use the Non-PAR fee schedule. Claims processed at a different % Provider waits for payment from Medicare & Secondary.

55 Non-Participating Providers Not accepting assignment: Providers would use the Limiting Charge fee schedule. Claims are processed at a different %. Patient pays the provider and waits to be paid by Medicare.

56 Medicare Documentation Requirements Each Subjective of a daily notes should have documentation of O P Q R S T O - Onset P - Provokes or Palliates Q - Quality R - Radiates S - Severity T - Time Each Objective of a daily note should have documentation of P A R T P - Pain, Tenderness A - Asysmetry / Misalignment R - Range of Motion T - Tissue Tone Changes

57 Billing Procedures Only covers for Spinal Manipulation Primary Diagnosis is Always Subluxation Each Subluxation DX Code needs a Condition or Illness Code Only covers Medical Necessity Treatment Based on Function and effects for Activities of Daily Living PQRS G-codes, Reporting the completion and documentation of Outcome Assessments and Function Disability Active or Acute Care AT modifier to Manipulation CPT code Maintenance Care GA modifier to Manipulation CPT code No coverage for Exam, Re-exams, Therapy ABN Form required when patient is Maintenance

58 C P T C o d e s Medicare Billing for Manipulation of the Spine 98940, or AT modifier Active or Acute Care 98940, 98941, or GA modifier Maintenance Care and a signed ABN form on file Modifiers: AT documenting Active or Acute Care GA ABN required to be signed, notice of liability issued GX modifier for all E/M coding Notice of liability issued GY modifier for services statutorily excluded from Medicare benefit GZ modifier for services expected to be denied as not reasonable and necessary

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60 Physician Quality Reporting System (PQRS) Pain Assessment Quality Code Measure #131 Functional Outcome Assessment (FOA) Measure 182 ONLY USE ON MEDICARE PATIENTS BILLING of Manipulation (exception: ASHN patients)

61 Report only when Chiropractic Manipulative Therapy (spinal manipulation) is performed on Medicare patients only 18 years and older Chiropractors can only report on the 1500 CMS form Effective 2015 It is NOT a required to report the Measure #317 Preventive Care & Screening and Follow-up Documented (High Blood Pressure)

62 Terms to Know Assessment Pain and Function Standardized Tools How to document the Assessment Pain Scale and Outcome Assessment Tools Follow-Up Plan Document of a Treatment Plan Not Eligible Patient refused to participate Patient is unable to complete questionnaire Patient is in an urgent or emergent medical situation, delay in treatment would jeopardize the patient s health status

63 Reporting the PQRS measures is essential for 3 reasons 1. To ensure that you are paid the maximum amount available for Medicare patients 2. To build as accurate of a performance database as possible for chiropractic procedures and for yourself 3. Documentation of the therapeutic benefits of patients by functional improvement

64 Choosing to Participate If you participate and meet the qualifications you will not be penalized in the future years with payment reductions AND In 2014 you will be eligible for PAYMENT Incentives Incentives will be issued of.05% of total allowable charges during a reporting period. Medicare carrier will issue separate check specifically PQRS Incentive Payment

65 Choosing to Not Participate If you did not satisfactorily report data or chose NOT to participate in 2013 This would be the result: * 2015 you will have a 1.5% payment reduction * 2016 payment adjustment will increase to 2% * Will effect the allowable amount you will use for your Medicare patients

66 PQRS Measure #131 Pain Assessment and Follow-Up Documentation of clinical assessment for the presence or absence of pain. Medicare Patients encountered Service 98940, 98941, or Patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of standardized tool(s) on each visit and documentation of a follow-up plan when pain is present. This measure is to be reported Each visit occurring during the reporting period for patients seen during the reporting period.

67 Examples of Pain Assessment Standardized Tools Brief Pain Inventory (BPI) Faces Pain Scale (FPS) McGill Pain Questionnaire (MPQ) Multidimensional Pain Inventory (MPI) Neuropathic Pain Scale (NPS) Numeric Rating Scale (NRS) Oswestry Disability Index (ODI) Roland Morris Disability Questionnaire (RMDQ) Verbal Descriptor Scale (VDS) Verbal Numeric Rating Scale (VNRS) Visual Analog Scale (VAS)

68 G codes - Reporting Pain Assessment G Pain Assessment as Positive and Follow-up plan Documented G8731- Pain Assessment is Zero or Low and Follow-up plan is Required G8442 Patient is Not Eligible for a Pain Assessment You really want to stay away from using these G codes. For 2 reasons: they may never apply to your office or the codes are telling Medicare that you did or didn t do the assessment or documentation of the assessment. -G Pain documented, NO follow up plan, Patient not eligible -G8732 No documentation of Pain, reason Not given -G8509 Pain documented, No follow up plan, reason Not given

69 PQRS Measure #182 Functional Outcome Assessment and Follow-Up This measure documents the use of standardized outcome assessment questionnaires. Medicare patients aged 18 years and older with documentation of current functional outcome assessment and care plan based on identified functional outcome deficiencies. Medicare Patients encountered Services 98940, 98941, or 98942

70 Measure is to be reported Each Visit for patients seen during the 12 month reporting period. A Current Functional Outcome Assessment is required. A Functional Outcome is multi-dimensional and quantifies pain and neuromusculoskeletal capacity. ADL s and Functional Disability are determined by patients completing Outcome Assessment s The intent of the measure is for the outcome assessment tool to be utilized at a minimum of Every 30 days, but reporting is required each visit.

71 Standardized Tools used for Functional Outcome Assessment Examples: (not limited to) * Oswestry Disability Index (ODI) * Roland Morris Disability /Activity * Questionnaire (RM) * Neck Disability Index (NDI) * Patient-Reported Outcomes Measurement Information system (PROMIS)

72 G codes - Reporting Functional Outcome Assessment G8539 FOA Documented and Follow-up plan Documented G FOA Documented and Follow-up Care Plan Documented G8542 FOA Documented, No Deficit, No Care Plan needed G8540- Patient is Not Eligible for the completion of a FOA You will probably never be use the following in your office, For 2 reasons: they may never apply to your office or the codes are telling Medicare that you did or didn t do the assessment or documentation of the assessment. G9227 FOA documented, Care Plan Not documented, Patient not eligible G8541 FOA Not Documented, reason Not given G8543 FOA Pain documented, Care Plan Not documented, reason Not given Please note: Documentation of the functional outcome assessment tool must include the name of the standardized tool used.

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74 Building a Practice Together Team Work Bonus System for CA s in all Departments Monthly Bonus Based on 3 Quotas Number of Kept Appointments Per Month Number of New Patients Per Month Total of Collections Per Month Doctor would evaluate previous numbers per month Set a Goal for each Month and Update it Each Quarter After the quarter then the goal would be increased by a certain %. Set a $ Dollar Amount Per Quota Hit Such as $50 per quota If all three are reached then extra $25 So in reality each CA could make an extra $ / Month

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76 Office Policies, Procedures and Systems There should be an up to date Employee Office Policy Manual, Compliance Manual and HIPAA Manual in every Chiropractic office. Employee Office Policy Manual Describing Policies for the actual Office Building and Practice Describing Employee Employment Policies Vacations, Sick days, Pay raises and more Office Compliance Manual Describing all Procedures, Policies and Systems in place for all employees to refer to complete their jobs. Example: What is the procedure when a patient has a credit on their account. HIPAA Manual All patients should be trained on HIPAA Policies to protect ALL Patients Private Health Information (PHI)

77 There should be an office policy manual and compliance manual describing all departments in the office, job descriptions and duties for each job. Employees should be educated and trained so they can perform the job efficiently. Regular Monthly Staff meetings should be scheduled so all employees can attend. Meetings are NOT gripe sessions, they should be discussions of current events happening in the office, Good and Bad. All Departments should have their own meetings to discuss in detail each department issues.

78 What it takes to have a successful Chiropractic Office with Less Stress Have current procedures, policies and systems in place. Staff that is organized, educated, consistent in their performance. Communication between staff. Everyone needs to be involved. Everyone needs to know and understand their role within the office.

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80 I have heard doctors say I have a compliance program and we are compliant my office is complaint as much as it is going to be or why do I need or have to have a compliance program

81 Why you should have a compliance program? 1 st of all it is a requirement for any provider of healthcare services CMS Medicare OIG Guidelines

82 Benefits of a Compliance Program Protect the practice against fraudulent and erroneous conduct. Ensures appropriate operating procedures from the patient intake forms, filing claims to collections, and future care of the patient. Addresses issues of coding and billing procedures.

83 Adds the word consistently to the working of you office and staff. Correct coding and billing procedures INCREASES REVENUE while REDUCING POSSIBLE LIABILITY associated with incorrect coding and billing practices Establishes monitoring procedures for the lifecycle of the practice

84 Compliance Program Definition: Operational Structure that will assist the physician s office to prevent fraudulent and erroneous conduct. Purpose: Integrate policies and procedures into the physician s office that are necessary to abide to federal and state laws to deliver healthcare services.

85 Compliance Program should be designed to meet the needs of each individual physician s office. ***you can purchase a template compliance manuals, but you have to design it specific for your office and your policies, services and procedures.

86 A compliance program is a living, growing and changing program It needs to be reviewed and updated regularly changes in your office procedures changes in the Federal & State Healthcare guidelines It can be used for reference and training If your office as ever investigated by the OIG, they will take into consideration if a compliance program was in effect before the investigation was conducted.

87 There are 3 areas a Compliance Program that should address: 1. Development 2. Implementation 3. Monitoring

88 7 Essential Elements of an Effective Compliance Program 1. Develop and implement written office policies to promote a compliance program. 2. Designate a compliance officer that is responsible for implementing & monitoring the written policies. 3. Develop and Implement scheduled education and training programs.

89 4. Develop and Maintenance of a complaint process for reporting alleged non compliant conduct. Non compliant conduct : Doesn t mean someone in the office is being intentional fraudulent or non complaint, it may just be the lack of knowledge or training. You need a reporting process to address that problem.

90 5. Conduct internal audits to monitor compliance requirements and regulations. 6. Develop a system to respond to allegations of improper conduct and enforce disciplinary actions. Again improper conduct could be unintentional and actions could just mean training for the employee. 7. Responding promptly to detected offenses and undertaking corrective actions.

91 In Conclusion As you can see a Compliance Program can be developed for your office. You can create your own, purchase a template and complete it to fit your office, or you can hire someone to create one for your office. In any case you must have a compliance program in place, regularly updated and followed.

92 Health Insurance Portability and Accountability Act

93 What is HIPAA, and what does it do? Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Department of Health and Human Services promulgates rules and regulations to regulate the privacy and security of medical information. The purpose of the law is to improve portability of health insurance coverage, reduce healthcare fraud and abuse and to protect individual privacy of personal health records.

94 Please note that after HIPAA went into effect, several sets of regulations were promulgated, two rules are key for marketers the Privacy Rule and the Security Rule. The Privacy rule creates national standards to protect the privacy of personal information, while the Security Rule governs the security of electronic healthcare information. Each must be reviewed by organizations that are using health information of individuals.

95 An Overview of Offences See in Offices Repeating patient health information (PHI) while on the phone or to other staff members with other patients to hear. Employee s being on Social Media (face book) on office computers. Giving out the office WiFi password. All staff members should have their own and passwords. Charts in the pockets in the hallway with patient s name out. Patient charts in reach or view of other patient s site line.

96 HHS announced changes in January, 2013 The omnibus rule, to provide the public with increased control over personal health information as a result of enhanced enforcement by the Health Information Technology for Economic and Clinical Act (HITECH) enacted as part of the American Recovery and Reinvestment Act of 2009 and other rulemaking proceedings since 2009.

97 Additional Updates to HIPAA Introduction to the HIPAA Security Rule Compliance Checklist Introduction to HIPAA Compliant HIPAA Compliant Hosting solutions are poised to provide systems that will ensure that health data falls within compliance for HIPAA, HITECH and EHRs. HIPAA Compliant specializes on secure . HIPAA Compliant Cloud Storage does the same for electronic storage purposes.

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99 Educating Staff and Doctors The Healthcare Profession changes constantly, so it important to stay abreast of the changes. Doctors and staff can do so by completing continuing education and training. Quarterly Training is needed to keep the office up to date on all the changes in the Chiropractic profession. On line free webinars are available from several companies and doctors.

100 Provider Credentialing

101 Provider Credentialing with Insurance Carriers Various types of practices and it is important to be billing correctly to all carriers. Sole Proprietor - 1 provider - Individual NPI - Bill using Tax ID or Social Security Number Group Practice - More than 1 provider - Individual NPI for each doctor - Group NPI for Practice - All Associate Doctors have to be registered with all insurance carriers - All Associate Doctors will assign their benefits over to the group Practice - Bill using Tax ID for Practice - All payments come to the practice made payable to Group Practice

102 Any questions?

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104 Sue Ware, MCS-P Board Certified Medical Compliance Consultant & Billing Specialist- Specializing in Chiropractic When you get back to the office and if you have any questions lease send me an at