PRACTICE MANAGEMENT CONSULTING

Louisiana Managed Care - Prompt Pay Law

This regulation is directly from the Louisiana State Department of Insurance
and is specific for manage care/indemnity plans
　

If utilized properly, you will ensure your collections without having to beg and plead

from the desk of:

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

The carriers have 25 days to pay or deny your claim if filed electronically and 45 days if filed by paper. Anything beyond that will result in a default of the payment of your claim and mandate a 12% penalty to be paid, by regulation. A telephone call will fall on deft ears, therefore create a paper trail with a demand for payment.

The Law:

§ 22:250.31, et. seq. (1999)
HB 885 (2005)

Language for your complaint:

Dear Claims Examiner:

The services rendered were billed within the Louisiana Insurance guidelines. It has now been beyond 45 working days allowed by Louisiana Prompt Pay Law, Section § 22:250.31, et. seq. (1999), HB 885 (2005)

Since you have violated this regulation we can submit this entire claim for summary judgment or arbitration through our legal counsel.

　We would like to resolve this issue without using legal counsel. If we do go to court, It will cost you both the amount of the claim and attorney fees with 12% interest annually as mandated by regulation Section § 22:250.31, et. seq. (1999), HB 885 (2005)

　We request payment within 3 weeks of the date of this letter for the resubmitted bill(s) as prescribed by law. By doing so we will waive the interest due us as described in the regulations previously cited. If we do not receive payment, we will be forced to litigate this matter and also file a complaint with the Louisiana Department of Insurance.

225-342-5900

Can only send emails on the website: http://www.ldi.la.gov/contact_us.html

Medicare Audits

MEDICARE AUDITS

by Mark Studin DC, FASBE(C), DAAPM, DAAMLP

It has been widely reported that Medicare will be auditing a significant amount of 98941 and 98942 codes nationally. As a coding consultant, I have been getting too many requests for help nationally from doctors who are not doing it right. The problem does not exist in the audit process; it is the doctor who does it wrong.

Getting paid and surviving audits are very easy once you understand your responsibilities as a provider. Rather than re-create an explanation, the New York State Chiropractic Association published the following article which accurately offers solutions to learning how to document compliantly.

The following was retrieved from http://www.nysca.com/?id=694

by Louis Lupinacci, DC and Mariangela Penna, DC
12/2/2010 3:11:56 PM

The current requests for audits by Medicare are not an unusual review.　　In　New York, there is currently a special services pre payment audit request for 98941 services as of October, 2010 and for 98942 services as of November 2009. Also, Medicare does ongoing CERT reviews on Chiropractic claims in which they will review records for proper documentation to support the claim and diagnosis that has been billed.
　
With the prepayment audit review, they seem to be sending a request letter for each patient and they are only asking for 3 months of records. A special services CERT request letter is usually 3-4 pages long, and they may ask for multiple patients or multiple dates of service, listed in chart form and they usually request 6 months of previous records.
　
According to Dr. Ritch Miller, ACA Medicare Committee chairman, you should and must comply. If for some reason you speak with anyone from the carrier/contractor, log the person's name, ID #, station number or whatever and write word for word what you are told. Normally we recommend not speaking with the contractor. KEEP TRACK OF EVERYTHING, and make 2 copies of everything you send to them.
　
Doctors are encouraged to review the Local Coverage Determination (LCD) for Chiropractic Services (L27350). LCDs can be accessed from the Medical Policy Center on the　web site; enter keyword L27350 in the Medical Policy Center search form field to access the Chiropractic Services policy. There is a detailed description on what you documentation should include for the initial visit and subsequent visits.
　
We also suggest before you start working on the audit, go to the ACA Medicare Webpage　and read the links on audits/appeals. You and your staff should take the free 2 hour ACA Medicare documentation webinar. Then, we recommend that you read everything else on the webpage. You need to know everything you can about Medicare, now. So even if you think you know everything there is to know about Medicare, you need to read everything once again. In particular, some of the things (but not all) they are looking for include the diagnosis with a subluxation to correlate with the service code that is billed (98940, 98941, 98942). There should be a treatment plan for the condition. You should note the level of the subluxation adjusted. A PART exam should be done on the onset date of the condition treated with subsequent periodic re-exams and function assessments. Finally, every visit should be signed in full by the provider of the service. If you have not signed your notes attaché an attestation page with the visits. This can be found at key word signature.
　
Other suggestions from Dr. Miller include the following. With regard to what documentation to send, we recommend you send everything in from the BOX 14 (CMS 1500) date on, even if it is a month or two longer than the 3 months, if that date is less than the 3 months then we suggest you send in 3 months documentation if the patient was treated at that time. Make sure you send all supporting documentation even if it is several years old, like the patients original intake forms if that has historical information on it, if this information is found in no other place in the records.
　
Many doctors’ first react with anger and frustration when they start to get these audits. That is not helpful and in past cases has made things a whole lot worse. Be as pleasant as you can be with anyone you speak with.　
　
Only send in patient records, do not send in any explanatory letters or anything that is not an "official" patient record, since it can be used against you and since it is not official it cannot be used in your favor.
　
If you get denied on any of the claim(s), you we recommend that you consider an appeal, if the documentation supports the service billed, even if you are asked to return only $20. It is a temptation to not go further, but that may be seen as admission of guilt and they more than likely will continue with future audits.
　
Hopefully this won't turn into the battle that many other states are going through across the country, but you must prepare for the worst and expect the best. There are doctors across the country, (and again hopefully you are not one of them), that have been carrying on this battle for over two years. So you must take this very, very seriously.
　
The ACA is working on this with CMS and hopefully we can turn this around. Unfortunately, with the executive branch and administration's increased and well publicized focus on fraud and abuse, don't plan on that.
　
If you have any questions, please first go to the ACA webpage and see if you can find the answer there. If not please contact Dr. Lupinacci or Dr. Penna. If you have any questions specific to this notice, please feel free to contact either of us also.

Florida Managed Care - Prompt Pay Law

This regulation is directly from the Florida State Department of Insurance
and is specific for manage care/indemnity plans
　

If utilized properly, you will ensure your collections without having to beg and plead

from the desk of:

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

The carriers have 20 days to pay or deny your claim if filed electronically and 40 days if filed by paper. Anything beyond that will result in a default of the payment of your claim and mandate a 12% penalty to be paid, by regulation. A telephone call will fall on deft ears, therefore create a paper trail with a demand for payment.

The Law:

Language for your complaint:

Dear Claims Examiner:

The services rendered were billed within the Florida Insurance guidelines. It has now been beyond (20 or 40) working days allowed by Florida Prompt Pay Law, Section §§ 641.3155, 627.613 (2000), SB 46-E (2002)

Since you have violated this regulation we can submit this entire claim for summary judgment or arbitration through our legal counsel.

We would like to resolve this issue without using legal counsel. If we do go to court, It will cost you both the amount of the claim and attorney fees with 12% interest annually as mandated by regulation Section §§ 641.3155, 627.613 (2000), SB 46-E (2002)

We request payment within 3 weeks of the date of this letter for the resubmitted bill(s) as prescribed by law. By doing so we will waive the interest due us as described in the regulations previously cited. If we do not receive payment, we will be forced to litigate this matter and also file a complaint with the Florida Department of Insurance.

Office of Insurance Regulation
The Larson Building
200 E. Gaines Street
Tallahassee, Florida 32399-0305

850-413-3140

http://www.floir.com/

S.O.A.P. 4 Critical Stand-Alone Letters

US Chiropractic Directory
"Preferred Member Consulting"
　
From the Desk of:

　Mark Studin DC, FASBE (C), DAAPM, DAAMLP

This consultation is being offered to every organization that utilizes my services...It is that important!!

"S.O.A.P.; 4 Critical Stand-Alone Letters

I attended the New York Chiropractic Council's state convention this past weekend; this is an organization that I co-founded in 1989 and have been very active since the inception at various levels from member to President (executive board of director) and most every other position. As a result of my participation, visibility and formally lecturing, I am known to most members statewide and my advice is often asked.

There are 2 types of advice that is sought; 1 is publicly in groups of doctors or in lecture settings and the other is in a hallway where I am asked to go to a private area to have a confidential conversation. This past weekend was no different as I had multiple doctors corner me and ask for a "confidential meeting." During these meetings, the doctor hands me a document request from either a licensure board, carrier or the government auditing the doctor and the doctor asks me what should they do. At least those are the smart ones as many come to me after the process is underway and they have "shot themselves in the feet."

The main topic of private meetings this weekend were all the same, each doctor was being audited by either CMS (Center for Medicare Services) or private insurance companies and were demanding copies of S.O.A.P. notes and evaluations. In each instance, I had the doctor re-create for me their S.O.A.P. notes and evaluation so that I understood what they create on a daily and monthly basis to better understand what they did.

Although the S.O.A.P. notes were taken in various formats from travel cards to full written notes to electronic notes, they all had 1 critical flaw in the process. The problem is one of "stand-alone."

The advice I gave to the doctors was to look at their S.O.A.P. notes conglomerately and individually to ascertain the condition of their patient. Here is the key, if you can look at an individual note and understand what is happening, then you are in great shape. If you have to go to previous S.O.A.P. notes and evaluations then you are exposed to having big problems.

For example, you cannot write in the subjective; "see previous note" or "improved from last visit." This does not give a story and that is what's required.

There are many level of audits and a simple letter from a carrier requesting 1 or 2 visits notes is a probing inquiry to see if you warrant a surprise inspection from the Office of Inspector General from Medicare or the SIU (special investigative unit) from private insurance companies or a subsequent request for every record of every patient for a particular carrier. Some of you might feel invincible and that your notes are perfect or that you are a healer and based upon your clinical results, you are bulletproof.

Here is the reality; if the carrier wants to audit your records, by law they can and there is nothing you can do at the end of the day to prevent it. There are some states, like New York that limits a carrier to 3 years in retrospectively auditing a doctor's notes, however if the carrier suspects fraud there are no limitations. This is the legal mechanism that all carriers use, they always suspect fraud and it is the easiest step to take when wanting to leverage a doctor to get their money back.

The carrier simply hires a doctor with credentials like mine or someone similar, pays them a lot of money and they say that all of your care, from the beginning of your practice was not clinically indicated. You might think that inflammatory, it isn't. I have been retained by many lawyers representing doctors in legal battles because they either didn't heed my advice or they put themselves in a position to lose. As a result, I have, through subpoena power been given all of the internal documents to review form the carriers giving me a unique perspective of how the carriers "get away" with making such inflammatory claims and selling it to the courts.

Will all of these claims bear out after a long, bitter protracted trial? Of course not, but the carriers aren't using them for that purpose. It is used for leverage against you and they are succeeding in getting that leverage against you in the form of legal turf. That turf is getting a case certified for RICO Antitrust putting you in Federal Court with a more expensive lawyer having you face treble damages, forcing you to produce massive amounts of documentation and having legal standing to stop paying your current and future claims that they know you will eventually forfeit.

Are you starting to get the picture?

In the past, I have strongly advised you to utilize the services of Dr. Michael Schonfeld (516-695-7732 or chirodoc006@gmail.com) to get a voluntary audit and many have heeded the advice and sleep much better knowing that you are doing it right, while others have all of the answers and remain targets.

Getting back to the subject at hand, your S.O.A.P. note; each note must be a stand-alone document. When the carrier audits 1 visit, they must see what is going on in that individual S.O.A.P. note. You must have the specific region well documented to give reason to care for that region. There must be a subjective reason for caring for the patient with objective findings and assessments for each individual reason.

The only area that is acceptable for citing previous notes is the care plan. It is here that you can cite "follow ordered plan" and must be documented on the most recent evaluation or re-evaluation. It is for that reason that auditors request both the documentation for the specific visit date and the evaluation associated with that visit.

Medicare clearly states that evaluations "MUST" be performed every 30 days and unless an individual carrier or state regulation alters that; that is your standard of care.

Many will argue that their patient only come once per month and my answer is; does that fall within the 30 days or not? You must re-evaluate your patient every 30 days, not every 12 visits, or 8 visits or 1 visit. The level of evaluation you perform (99215, 99214, 99213, 99212) is based upon clinical necessity and you get to determine that; just ensure that your documentation certifies the level of evaluation you coded. If you need help with forms, go to: http://teachchiros.com/index.php/forms-a-templates

If you feel this process absurd, silly, stupid, a waste of your time then you are much smarter than I am because these are the rules and standards of our licenses. I am dumb enough to know to follow the rules as long as I want to stay in the game. I didn't create the game of being a licensed chiropractor, but I like it and want to stay in it while earning a living for rendering quality care.

Follow the rules!