Surveying the new landscape in an ICD-10 world.
By the time you read this, we’ll have just passed the ICD-10 implementation date. So that happened.
And now we can all relax, right? No, that wouldn’t be the best thing to do.
Having labored long and hard, we’ve arrived at this triumphant moment when the nation’s healthcare providers are all using an entirely new coding language. It’s nothing less than the biggest change in healthcare in over three decades. But instead of being able to rest on your laurels, you’re under more pressure than ever before. It’s frustrating. It’s unfair. And it’s also the new reality.
Office of Inspector General
You might remember, back before ICD-10 preparations kicked into gear, that the Office of Inspector General (OIG) released its most recent Work Plan. Let’s review how that plan was relevant to chiropractic:
A whopping 75 percent of the OIG’s funding is devoted to Medicare and Medicaid oversight. And since chiropractors can’t “opt out” of Medicare, that means the OIG is spending a chunk of its budget taking a look at you and your colleagues.
- Do you know what Medicare wants to see in your documentation to support medically necessary care? Equally importantly, are you actually doing it?
- What would happen if the OIG decided to take a close look at your practice? Would your documentation hold up, or would you be at coughing up recoupments?
“But I don’t treat that many Medicare patients,” many of you are saying. “This isn’t going to affect me.” Here’s the thing: Independent insurers look to the OIG and Medicare to set the pace and tone of billing rules, and tend to fall in line and enforce the same guidelines. Even if you were “safe” from Medicare (and there’s truly no such thing), you’re likely not safe from all of your contracted carriers.
- How would your documentation stand up to closer scrutiny by any of the carriers with whom you have a contract? Do you know what they want and expect to see?
- Could you handle it if one of them came after you and began demanding that you send money back—money you’ve probably already spent?
Why can’t these people just leave you alone? There are a few good reasons. In fact, there’s about five billion of them. The OIG estimated its 2014 intake from last year’s audits and investigations at $4.9 billion. Do you think the government is going to turn its back on that kind of money? Do you think that private insurers haven’t sat up and taken notice?
The OIG genuinely believes that improving chiropractic documentation is good for the profession. But it also believes the best means to that end is to put your documentation under a microscope, shake it around a bit, and see how much money falls out.
Risk and reimbursements
You’ve already put emergency money aside in case there are delays in reimbursements post-ICD-10. Can you handle it if, on top of potentially delayed reimbursements, you find out you have to give back a bunch of money you received last year?
Do you think you are safe from government or private-insurer scrutiny? Sadly, practices that have already been through an audit aren’t immune. There are DCs who’ve been through this stressful process again and again.
These are only the potential financial ramifications. But there are far worse possible outcomes of an audit, and the news is filled with stories of doctors who’ve lost the luxury of assuming they’ll get paid (because they are now required to submit documentation in advance of treatment, almost like being “pre-audited,” until they re-earn trust).
There are also the doctors who lost their freedom by being sentenced to jail time. And doctors who lost their livelihood. It doesn’t happen often, but egregious offenders can lose their license to practice.
Still skeptical? During 2014, the OIG:
- excluded 4,107 “individuals and entities” from participating in federal health insurance programs (how quickly do you think private insurers followed suit?);
- brought 971 cases of criminal charge; and
- filed 533 civil actions against
If that doesn’t get your attention, it’s hard to imagine what will.
It would have been better had the OIG headed into 2015 confident that DCs were all going to straighten up and fly right, but it didn’t. The government entity has had enough experience to know that many chiropractors are poor documentarians, and it has said—in writing—that it will be stepping up its efforts to identify and bring to light cases of abuse, noncompliance, and fraud. And it has kept its word.
The news is rife with cases of doctors who are getting punished, and punished severely, sometimes for outright fraud and sometimes for sheer ignorance.
One DC had to come up with almost $800,000 in recoupments because he was coding all of his treatments as five- spine adjustments, whether medically necessary or not.
You don’t have to read the OIG’s 90-page Work Plan, but do take the risk of being audited seriously. Get crystal clear on what documenting for medical necessity looks like—especially now that you’re coding with ICD-10.
Learn from documentation errors
Your chances of making innocent documentation errors that put you at risk are greater than ever before. CMS has said that Medicare won’t reject claims for incorrect codes alone, as long as those codes are in the right coding family. But this will do absolutely nothing to protect you from other kinds of documentation mistakes and their ramifications.
So on this particular “morning after ICD-10,” things are not quite as safe as we’d like them to be. But that doesn’t mean you face a reign of terror, either. Doctors who’ve put their nose to the grindstone, located their coding errors, and made a true effort to fix them have seen great turnarounds. Many practices put on probation have worked their way back to full privileges again.
The OIG doesn’t think DCs know how to document correctly. Let’s prove them wrong.
Kathy Mills Chang, MCS-P, CCPC, is a certified medical compliance specialist (MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. She leads a team of 16 at KMC University and is known as one of the profession’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562, firstname.lastname@example.org, or through kmcuniversity.com.