CMS requires health care professionals to certify on claim forms that services and items provided like spine images are medically necessary
The medical community heavily promotes health screenings — women are having pap smears often beginning in their late teens and mammograms in their 40s.; men are having prostate screening in their 50s; colonoscopies are recommended as you hit 50; and lastly, let’s not forget your teeth and great smiles. It is recommended that people go to the dentist twice a year for cleanings.
As chiropractors we recommend intermittent adjustments to keep proper spinal alignment as preventative measures which can help the overall health as well. As chiropractors should we be promoting to patients and others unaware of the benefits of chiropractic care the importance that spinal health screening and care should begin at an early age — the philosophy of “from the cradle to the grave.”
Promoting wellness in chiropractic
Just as other health care practitioners heavily promote wellness care, so should chiropractic. Promoting to your patients that coming in for routine care or maintenance care just as dental cleanings every six months can help to avoid the onset of catastrophic or debilitating pain. Preventative spinal care can improve the probability of better future outcomes. All this screening is designed to catch problems while they are small.
Some people avoid screenings or recommended tests because they are fearful of what might be uncovered. They just don’t want to check things out for fear of bad news. Can you imagine ignoring tell-tale signs of masses or bleeding or inability to urinate? Had the appropriate screenings or tests been performed, the results might not be as devastating.
Taking short cuts
How do you monitor your practice’s health? Would it be determine based on collections? Or, would it be based on how many patients are scheduled on a daily basis? Is it how full your schedule is?
It is interesting when we as compliance officers ask doctors how their documentation of patient notes are — we hear “It’s fine,” “I’m on top of it,” or “I am 100% compliant.” Perhaps, a more appropriate question should be, how healthy are your notes and do they demonstrate medical necessity? Many times as human beings we do the same things over and over, day after day, we can develop a tendency to start taking short cuts and not even realize it. When taking short cuts, the attention to detail in documentation is lost, critical and necessary elements of treatment notes are left out.
Spine images and medical necessity
There is a strong correlation between correct documentation and positive outcomes if your claims are audited. To best determine if your documentation contains all the required elements to meet the set standards is to have your patient charts reviewed by unbiased, well trained and certified individuals to ensure medical necessity and proper coding is proven.
Is your version of meeting medical necessity the fact that a patient came into your practice, or is it “because I am the doctor and I say that the treatment/adjustment I am giving is medically necessary”? Medical necessity is based on a combination of elements that must be proven through proper documentation. Proper coding, which is determined by good documentation demonstrating medical necessity for the need of chiropractic manipulative treatment, leads to a healthy practice.
Avoid the ‘HEAT’
In 2009, the DOJ and the U.S. Department of Health and Human Services joined forces to form the Health Care Fraud Prevention and Enforcement Action Team, or HEAT, to strengthen fraud prevention efforts. They use data mining from submitted claims in addition to tips and complaints they received from their hotlines. While most doctors and staff are honest and dedicated, a few dishonest providers have tainted the view of the chiropractic industry. Waste and abuse may be unintentional errors, but when errors go uncorrected, governmental agencies may view these errors to be fraud. Current real-time claims analysis and data mining methods provide prosecutors the ability to target providers reporting higher utilization of certain procedures like spine images and procedure codes as compared to their peers, thus scrutinizing medical necessity from a criminal perspective.
Though a patient may benefit from care that is provided, the documentation must show a direct correlation between presenting complaints and treatment delivered. Documentation must include any testing or exams utilized to demonstrate medical necessity, the area of the spine adjusted, the technique used for each area of adjustment, and finally how the patient tolerated the treatment.
Data mining has provided a method to correlate the number of services rendered and the average number of services required for the specific diagnosis and coding. The average number of services is then considered the standard of care.
Reimbursement and fraud
The federal government views “worthless services” as fraud, and it is important to understand what it is. Under the worthless services theory, when a provider bills the federal government for a service that the provider knows, or should know, has no value, the provider has defrauded the government. The government has the use of criminal statutes to address the issue of quality of care covering submission of claims for medically unnecessary treatment. Providers are reimbursed for services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
It is important to remember that an item or service rendered as medically necessary, for example spine images, is not dependent on a provider’s clinical judgement. The decision rests with the secretary of HHS for federal health care plans. Failure to adhere to medical necessity guidelines may not only constitute a civil False Claims Act violation, but could constitute a civil judgement if a provider knowingly and falsely represents the medical necessity of service in the submitted claim.
Criminalizing medical necessity
CMS requires physicians to certify on claim forms that services and items provided like spine images are medically necessary for the health of the patient (Box 31 on claim form 1500). Medical necessity determination during an audit can be unnerving since CMS has not precisely delineated what constitutes medical necessity or what documentation is required to substantiate it. Despite this lack of clarity, the government has chosen to criminalize medical necessity.
All major insurance companies follow the Medicare rules and regulations. Providers who do not want to be under the scrutiny of Medicare regulations fail to see that all major insurance companies have adopted Medicare regulation. There is no getting away from it. Even if you have a cash practice, that one malpractice claim will cause review of your documentation holding you to the highest standard of care.
For the health of your practice, it is important to have your documentation and claims screened to ensure your documentation is healthy as well, and is able to stand the scrutiny of an audit or investigation. There will be a greater chance that you will receive your reimbursements more rapidly because claim denials will be reduced as well. Be proactive with the health of your documentation, for the health of your practice and your patients.
DIANE M. BARTON, DC, MCS-P, CIC, is with Medical Compliance Specialists, Ltd., in Homewood, Ill., and can be reached at 708-922-3911 or drdianebarton.com.
1 Entering a New Era: Criminalizing Health Care Non-Compliance by Gary W. Herschman, Jack Wenik, and Daniel C. Fundakowshi, Epstein Becker & Greene, P.C. AHLA Connections August 2015
3 Social Security Act, Section 1862(a)(1)(A)