More and more DCs are sharing practices with MDs, DOs, PTs, MTs, acupuncturists, psychologists and other healthcare professionals. One of the reasons for this trend is that some DCs are getting locked out of managed care, which is starting to include Workers’ Compensation and Personal Injury in some states.<2/p>
More and more practice-management consultants are giving chiropractors advice on how to set up “integrated” multi-disciplinary practices. Specialized attorneys offer legal expertise on keeping these types of practices from running into trouble with the federal government. These professionals stress what is called a compliance program. Compliance is conformity to local, state and federal regulations regarding third-party payer system guidelines. One of the best ways to keep an integrated practice compliant is through computerized documentation.
Advantages of Integration
Integrating traditional medicine with alternative healing changes the way providers view and treat the patient. It also changes the way third-party payer systems view and process their information. Hurdles will need to be crossed with this new venture, especially because DC-run practices are now receiving benefits historically afforded only to MD-operated clinics.
The good news is that the integrated practice is here to stay, because it offers many advantages to providers, patients and the clinic operation.
For the patient:
- A patient referred to an MD or other healthcare provider can see a member of the referring practice’s staff. The patient does not need to call another office to schedule an appointment, and there is usually a shorter wait before treatment.
- The patient may receive better care because the patient file is centralized and other doctors in the office have easy access to the information.
For the provider:
- Providers from different specialties can easily confer on a patient’s case to provide better care.
- More efficient understanding of the patient case allows doctors to better assess their medical necessity for payment of services.
- Chiropractors and other providers working with an MD can more easily review treatment procedures and maximize reimbursement by the highest allowable provider in the clinic based on published reimbursement schedules.
For the clinic:
- Offices do not have to make copies of patient records, X-rays, etc., to send to doctors at different locations.
- Clinics may have less of problem getting pre-authorizations because they have the patient information more readily available.
Crackdown on Fraud
Attorney General Janet Reno has stated that healthcare fraud is the No. 2 priority of the U.S. Department of Justice, right after violent crime. During the 1980s, there were too many fraudulent billing practices that took advantage of the system and sparked the current backlash. The federal government has created mandates to investigate and prosecute healthcare providers who violate regulations.
Federal agents are cracking down on healthcare fraud using methods such as interviews with business partners and suppliers, or even investigations using undercover agents and electronic devices such as wire taps and bugs. Data profiles from your HCFA claims can be compared with codes used by peer groups in your area. This provides fuel for investigations. Patients and even your own staff members can report suspected violations.
Many doctors investigated by the government for healthcare fraud have been traumatized. The law states that you get penalized if you knew or should have known you were committing fraud.
The government’s emphasis on healthcare compliance is occurring in part because of increased computerization within the health-insurance industry. Increasingly sophisticated computer systems are in place that track and correlate payment of healthcare services with the doctor’s diagnosis to determine medical necessity. In the managed care world we live in, medical necessity is the rule.
The HCFA form is the vehicle that communicates the doctor’s diagnosis, the procedures performed, and the necessary patient and clinic information so the doctor/clinic can get paid on the claim. Over the past decade, the transmittal of HCFA forms has become increasingly more computerized with the advent of electronic form submission. Third-party payor systems have gained cooperation from many clinics to submit HCFA claims electronically (the practices get paid more quickly, have less paperwork, printing, handling, mail costs, etc.). This system also lets the insurance companies collect electronic information more efficiently.
Insurance companies now have masses of informational databases for tracking and correlation purposes. In the electronic age, printed HCFA forms are scanned in and become electronic information. Data profiles are easily created from HCFA forms. These profiles let insurance companies track doctors who are over-utilizing or under-utilizing certain codes as compared to their peer group in an area.
Is it any wonder that you are getting denied payment more frequently? With the arsenal of electronic information for analysis, the third-party payer system is capable of doing correlation of the information not only on a new HCFA claim form, but also the information submitted on all the HCFAs on a patient case with the patient’s past history. The information can be analyzed and processed more efficiently because of electronic submission. This technology has caused even more requests for documentation to substantiate treatment and determine medical necessity.
The Paper Chase
Keeping track of paperwork continues to be a significant problem, especially in larger practices and integrated practices with different doctor specialties using a wider range of codes. The challenges include:
- There is way too much paper per patient per visit (some estimate 10 to 20 pages per visit).
- Having more patient visits per day causes a greater need to process information, which increases the chance of errors and increases the potential exposure to fraud.
- Any staff will experience a percentage of natural human error. A clinic that sees 50 patients per day will perform, conservatively, three to four procedures per patient, which adds up to 150 to 200 transactions per day. With that volume, it is easy to make two paperwork errors per day. That translates into approximately 40 errors per month. According to federal law, reporting procedures incorrectly on HCFA forms can cost up to $10,000 per line item.
Because the payer system is computerized and can more easily identify inconsistencies in patient claims, fraud claims and investigations are becoming more common. Since many clinics see more than 50 patients per day, they have to process a minimum of 500 pieces of paper per day. Clinics that see 100 to 200 patients a day with different type of doctors are in an even more challenging situation.
Again, the law states that violations of regulations do not have to be deliberate to be considered fraud. If a fraud case is investigated or audited and the doctor is found guilty, the most lenient result is a denial of payment of services. Other possible punishments are high fines, clinic shutdown, and possibly criminal charges.
Leveling the Playing Field
Because the third-party payer system is computerized, healthcare providers are at a disadvantage unless they are, too. Most of you are already computerized for billing. Your HCFA forms are now easily dissected. It is only a matter of time before computers can dissect your documentation and compare them to your HCFAs. This is already starting to happen. Just look at managed care pre-authorization forms.
The insurance industry can easily review procedures and correlate them to diagnosis by doctor types. Insurance companies have programs written to enforce the rules of such relationships. They can automatically print letters asking for more information or worse, reject payment. For these reasons, it has become standard to prolong or deny payment on your services. Computerizing your practice’s documentation system is one of the best defenses you have.
There was a time when insurance companies asked only for a narrative report. Over the past few years, it has become standard practice to ask for daily progress (SOAP) notes. This trend can cause administrative difficulties for the chiropractic office, including:
- Requiring daily progress notes tends to slow down the doctor, so some take inadequate notes; thus, the payor can more easily prolong or deny payment.
- Doctors’ handwritten notes are sometimes illegible, which again means that payment can be easily denied.
- When a patient is treated many times, as is the case in chiropractic and rehab, it is easier for the insurance company to look for and find inconsistencies in treatment.
Insurance companies have begun to ask for complete files, including notes and narratives, in part because they are looking for inconsistencies in treatment. This lets the insurance companies compare the information on the HCFAs to the notes and narratives. You can help level the playing field by computerizing your documentation. You should make sure the documentation system:
- Uses the same information to develop both your SOAP notes and narratives.
You do not want to end up with different sets of information depicting your patient cases in the daily notes versus the narrative documentation. Another problem occurs when one doctor in the practice uses software, another dictates, another uses check-off forms, etc. This type of system makes for disjointed documentation of your patients with a higher degree of inconsistencies. Every doctor in the practice should use the same, computerized documentation system.
- Is well-researched and based on medical journals.
You do not want to get caught defending information that is not backed up by scientific journals. Throw into the mix the different scope of expertise needed for a multi-discipline practice, and the software will need a vast range of exam and treatment protocols to effectively document cases for each of those providers.
- Fully supports the information on your HCFA forms.
If it doesn’t, you are not only going to be denied payment; you could be accused of fraud.
- Provides you the capability to track whether your procedures are compliant for the diagnosis submitted on your HCFAs.
If you have a multi-discipline practice, the system must also allow you to submit claims by doctor type.
- Is the driver for your billing.
The doctor should start the process. Even if you have the correct procedures for the correct diagnosis on your bills, if your documentation does not concur and support the billing information, you have a problem.
A Growing Trend
This article is not meant to cause undue alarm. However, the need for compliance is just starting. In the next few years, compliance is going to be a rule. You are going to have to substantiate more and more because the payor system’s organized computerization will more easily find inconsistencies between HCFAs and documentation.
If you are working with a consultant, make sure that person offers a compliance program. Having a voluntary compliance program in place can minimize fines and other headaches. The initiative shows that your clinic has guidelines in place in an effort to guard against any fraudulent activity.
An effective compliance program must be very detailed because the computerization of the third-party payor system means that insurance companies can more easily require and process detailed information. In the past, some clinics that tried to develop compliance programs became overwhelmed and questioned whether they could succeed in meeting the requirements. However, it is no longer a question of choice. You need to be armed with the right computerized system to assist you in meeting compliance requirements, and luckily the appropriate software tools are now available.
Good documentation software uses an algorithm that calculates the patient history, exam depth and medical decision-making to provide the doctor E/M level qualification. This type of system is necessary to effectively computerize an integrated practice. The documentation cannot be accomplished manually.
Look at the 1999 American Medical Association and Chiropractic code books, and you will get an idea of the complexity required in the federal guidelines. For example, if the doctor takes two X-ray views of the cervical spine versus three views, it can change the data level from limited to minimal, which can change the complexity of decision-making from low to straightforward, which can change the E/M level from 3 to 2.
It is only a matter of time before insurance companies will be able to electronically determine if you have met the exam depth requirements in complete detail for billing at E/M level 2, 3, 4, or 5. Presently, too many doctors do not even understand E/M levels. Computerization helps educate doctors so they can effectively meet compliance guidelines.
Natural Evolution of Business
Is this increased need for documentation an insurance company conspiracy to increase profits and take advantage of the doctor? No, it is actually a natural business evolution. Because of computerization, the Internet, etc., business systems in general have become smarter. Staying current with the technology will help your practice take full advantage of the benefits within the healthcare system.
Make sure that you document correctly. While billing is an important part of getting paid, documentation can keep you out of trouble. Does that mean you should only buy documentation software that also has billing? No. You should start with the best billing and best documentation products. If they are progressive, they will link and offer you an integrated solution. Then you will have a fully computerized system, from the patient to the doctor, to billing, to the third-party payor system.
Do not wait to get your house in order. Prepare a compliance program now and make sure computerization is part of the plan.