Under the radar
How to avoid getting flagged
By Marc Sencer, MD
Thanks to the current economic climate, people are tightening their belts. Third-party payers are no exception.
The past two years have seen increasingly aggressive efforts by Medicare and private insurers to decrease reimbursement at the time of the claim, or recoup the money after the claim has settled. You can expect this trend to intensify.
While the need for good notes and documentation of medical necessity is frequently discussed, your best defense is not getting flagged in the first place.
“Flagging” is increased scrutiny and attention to your practice by third-party payers and can take various forms.
The most common types of flagging are:
The last form is especially damaging because there are cases where a hold is placed on all of a flagged doctor’s claims until the claim in review is settled. This can take months! Some states have regulations to curb this type of abuse, so know the rules for your state.
Although many factors go into flagging and each payer claims to use their own algorithms, you can avoid being flagged by avoiding some common scenarios.
Scenario 1: Always billing level four and five evaluations and re-evaluations and using the consultation codes for most initial visits. (Note: Medicare has eliminated the consult codes, so check with your other payers before billing them at all.)
Payers have a bell curve for each specialty and have a very good idea of what the normal distribution of level one – five visits for a typical chiropractic practice should be.
Scenario 2: Billing a visit with a procedure done by the same provider on the same date of service. Yes, you can use the .25 modifier for the visit and you are supposed to get paid, but many payers will deny you anyway.
Scenario 3: Billing manual therapy and an adjustment by the same provider on the same date of service. Even if you treat different areas and use the correct modifier, you will still likely get flagged.
Scenario 4: Not following the correct coding initiative for Medicare patients or the payer’s written policy on codes that may not be billed together for private insurance patients.
Scenario 5: Over-utilization. Payers know what percentage of patients will typically receive service, how long it will continue, and what reasonable charges are.
Some areas that receive extra scrutiny are: trigger point injections, manipulation under anesthesia, certain neurodiagnostic studies, and durable medical equipment such as TENS. That is not to say you should not order these treatments as necessary, but be aware that if your pattern of using them differs from other providers, you will probably
Your best defense
What is the best defense against flagging? First, have good people doing your coding and billing. For example: Practices that consistently make simple errors with modifiers will often get flagged.
Next, create an insurance profile for each payer’s practices for every code you bill. Use this as a guide for how you handle different billing scenarios.
With this information, you should always have a choice as to how you will choose to bill or not bill a particular service. For example: If you know two codes cannot be billed on the same day and the patient needs the services, you can give them the option of having each on subsequent days.
One of the best defenses against flagging is creating an integrated group practice with medical doctors, physical therapists, and physician extenders. Many insurers have limited benefits and strict requirements on the number and frequency of visits for chiropractic treatment, but have very different standards for medical or physical therapy care.
An orthopedic or physical medicine and rehabilitation practice typically will have greater billings for visits, diagnostic tests, and therapy modalities than a chiropractic practice. Bills that would trigger an audit coming from a chiropractor may be seen as perfectly normal for an orthopedic practice by payers.
In addition to protecting you from over-utilization flags, an integrated practice will allow you more freedom to perform procedures together that you otherwise could not bill.
For example: A patient may receive manual therapy from the physical therapist and an adjustment from you, without raising a flag.
Flagging can have consequences that range from having to resubmit claims to interruption of cash flow due to review. Fortunately, you don’t have to let it happen to you.
Check your knowledge about how to avoid getting flagged with this true or false quiz.
[ ] 1. Getting flagged will not be a problem if you have good notes.
[ ] 2. Some states have rules that limit a payer’s ability to use or hold up claims from other accounts to settle claims in review or recoupment.
[ ] 3. Keeping a payer profile is optional for small practices.
[ ] 4. Having an integrated group practice can give you greater billing flexibility and protect you against some types of flagging.
Nos. 2 and 4 are true.
Nos. 1 and 3 are false. Even if you feel you can argue successfully, the insurance company may still deny your claims, or worse, put you in review. The lost time and potential lost cash flow may not be worth it.
A payer profile is essential to know how a payer usually will respond to different billing scenarios.
Marc H. Sencer, MD, is the president of MDs for DCs, which provides intensive one-on-one training, medical staffing, and ongoing practice management support to chiropractic integrated practices. He can be reached at 800-916-1462 or through www.mdsfordcs.com.