The medically integrated practice presents specific rewards as well as challenges
Over the past few years, many chiropractors have begun pursuing the idea of a medically integrated practice. There are many benefits to incorporating other aspects of health care (i.e., neurology, orthopedic, physical therapy, occupational therapy, nurse practitioners, etc.) to ensure that patients are getting the best possible care by offering one-stop shopping and streamlining communications between practitioners.
“This means that medical errors are minimized, unnecessary tests avoided, prescription painkillers reduced, and patients ultimately will receive complete care,” Jesse Cooper, DC, told the American Chiropractic Academy (ACOM Health, 2019). However, there are stringent guidelines and legal ramifications if an integrated practice is not set up correctly.
The medically integrated practice: assume auditing and prepare accordingly
According to Mark Sanna, DC, ACRB LEVEL II, FICC, also featured in this issue, “State corporate laws and scope of practice regulations control how multidisciplinary practices must be formed and operated. These requirements vary dramatically from state to state.”
He strongly recommends retaining a health care attorney familiar with group practice health care laws and regulations in your state. And compliance doesn’t end after the corporation is established. Before adding a service, research the relevant state regulations, including who can perform it, in what setting, and how it can be billed. Assume everything will be audited and prepare accordingly.
You should also review the medical policies and provider agreements of the insurance carriers in your state. Often you will see language that prohibits billing physical medicine services by more than one provider on the same day or limits on the number of units or services that can be provided the same day. For example, this means if you provide a 98940-98043 service, it may count as a unit or service, which could take away from the number of timed units provided by a physical therapist.
Review applicable new E&M codes
In practices with multiple providers, you should also be aware of the number of E&M codes that can be provided in a single day, particularly since the services may be billed out under the same tax ID number. If you should refer a patient who entered the office to see your nurse practitioner, but was subsequently referred to you, the E&M service you provided may not be covered.
Laws and regulations governing health care apply to any health care entity specific to certain programs such as Medicare. For example, the Health Insurance Portability and Accountability Act (HIPAA) established national standards for electronic health care transactions, which apply to nearly every health care practice (OCR, 2017). On the other hand, the federal Physician Self-Referral Law applies specifically to Medicare and Medicaid. However, some states have their versions of such laws, which may be broader than the federal version, such as applying to all health care payers, not just federal health plans. There are regulatory instances where a medically integrated practice could run afoul if they are not careful.
Anti-Kickback Statutes
When operating a medically integrated practice, you must be aware of the federal and state Anti-Kickback Statutes (AKS) and fee-splitting prohibitions. AKS is a federal criminal law that forbids exchanging or offering to exchange anything of value to obtain getting referrals of any federal government health care business. They can be violated by paying or offering bonuses for referrals for other services. They can also be violated by providing free or reduced rates for office space with contracted providers.
Many providers are not aware that the AKS can be triggered by not charging for each and every service you provide. If a patient who saw the nurse practitioner first was referred to you for evaluation, if the service is not covered because it was provided on the same day and under the same tax ID number, you must charge your actual fee for the service. You should not offer it at no charge or at a reduced fee just because they saw your nurse practitioner first. Doing so would be considered an inducement violation.
Conviction on even one charge can result in five years in jail, $25,000 in fines, and exclusion from the right to participate in any federal health care program (not just Medicare or Medicaid).
False Claims Act
This law prohibits doctors from presenting false claims to the government for payment of medical bills. False claims include overbilling and billing for services that did not occur.
The chiropractor/medical clinic combination can create the risk of false claims since the health providers often bill at different rates and provide different services (Cohen Healthcare, n.d.). How would this occur? If a patient saw the MD or nurse practitioner first and was charged an E&M code, then they saw you, and you did not charge your actual fee or include the service as part of the prior evaluation, the fact that you didn’t charge for the billable service could be considered a false claim. Meaning, you didn’t report the service.
If you used a lower-level E&M code to lower the cost, that is considered down coding, which is a false claim. Many providers think that a False Claim Act (FCA) violation only occurs if you bill for a service that was not provided. The reality is, not billing for any service that was provided is also considered an FCA violation. The OIG levied an $80,000 fine to a chiropractor recently for not charging for muscle stim. The doctor may have thought that since Medicare does not pay for this service when provided by a chiropractor, that he would simply waive that charge. How did a $15-20 service lead to an $80K fine? Because these violations are a “per-occurrence” fine. They add up fast!
Physician, don’t refer thyself
Self-referral is the practice of referring patients to health care entities in which the referring provider has a financial interest. Because of the inherent conflict this creates between the provider’s financial considerations and his/her medical judgment regarding the patient, such referrals are prohibited by most states and under federal law (CMS, 2021).
A medically integrated practice, unless properly structured, could implicate federal and/or state self-referral laws. Assuming that the collaboration is structured as two entities, if the chiropractor or medical doctor owns an interest in both entities, there could be a self-referral problem.
The barriers to medically integrated practices — regulatory, administrative, financial and ideological—are considerable but can be profitable when set up correctly. If implemented correctly, it works well for patients, staff, providers and owners. Ultimately, you must consider the risk-reward ratio.
Even if you set everything up perfectly, you must understand and accept that the sheer creation of a medically integrated practice elevates scrutiny and your profile in the eyes of payers and regulators. To minimize your risks, you should consider hiring a compliance officer or outsourcing your compliance. You should also make sure that your financial policies are bulletproof. If you are offering any type of discounts to patients who may see multiple providers, make sure they are legal and compliant with all levels of regulations and your provider agreements. Finally, contact your malpractice carrier to see if they offer additional coverage for billing and regulatory investigations. Often for less than your malpractice coverage, some companies can add up to $1 million in additional coverage to your malpractice policy that will help cover fines and penalties that might be incurred.
Delivering the highest standard of care
To become an effective integrated practice, the most crucial step is to create a clear vision of the mission and purpose of the business. Determine why this comprehensive care approach is worthwhile, dig into the nuts and bolts of operating it, and then execute those ideas.
The primary goal must consistently be delivering the highest standard of care to patients (Higashi, 2016). Incorporating best-practice concepts, no matter what the structure, is an essential part of creating a successful integrated practice. This is clearly an instance where “lawyering up” on the front end is imperative and much less expensive than hiring a lawyer if a problem arises.
For those who choose to do it right, medical integration can be a rewarding and profitable investment and provide a higher level of service for your community and the patients you serve.
RAY FOXWORTH, DC, FICC, MCS-P, is a certified Medical Compliance Specialist and president of ChiroHealthUSA. A practicing chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as president of the Mississippi Chiropractic Association, is a former staff chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a Fellow of the International College of Chiropractic.
