WOW! Kathy s. Words of Wisdom. In this issue: August 2013 Theme: Fees and FInancial Policy. Kathy s Opening Message. Script of the Month

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1 Kathy s WOW! Words of Wisdom August 2013 Theme: Fees and FInancial Policy In this issue: Kathy s Opening Message Script of the Month KMC University s Q&As The Compliance Corner The Reimbursement Room Breaking News Product of the Month Preferred Partner s Corner Upcoming AnswerCall and Live Webinar It s been said that Happiness is a positive cash flow! The easiest, safest, and most profitable cash flow is that money that comes across the front desk as cash. While nobody wants you to shut the door to insurance, maximizing and nurturing the patient payment side of your practice is where foundational cash flow lies. This month, we focus in on the patient finance areas of practice. This is an area that is far too often overlooked and neglected. This month s newsletter has many different ideas to implement in your patient financial department. As we wind up the summer, commit to installing at least one to move your practice toward greater financial ease! Here s hoping we re going to see you at our Hands on Lab next month! Don t miss the opportunity to be with us in this unique and powerful weekend of compliance, finances and documentation! You won t regret it!

2 Script of the Month Fee Structures: Educated Patients are Patients for Life In your practice you probably have several layers of fees that include your Actual Fee, Contracted Fees (fee schedule with the payors you are contracted with), Time of Service Discounted Fees (5-15% when paid at time of service), Uninsured and Underinsured Fees (cash fees), and Hardship Fees. Within your practice you may receive a range of reimbursements for one single code that can vary by $20 or more, depending on the fee system your patient is attached to. But think about the patients you have worked with. Has there ever been a time when a patient went from one fee system to another during a course of treatment or between treatments? This could happen when: A patient goes to maintenance care, and is no longer covered A patient has exhausted their benefits A new benefit period has started and the patient is still in active treatment A patient changes insurance companies A patient no longer carries insurance A patient has been in a personal injury accident It is important that your patient understand your ACTUAL FEE, and any discount they are receiving based on your legal fee structure attached to their account due to their particular circumstances. When KMC University s Q&As Q: Am I able to provide a service for free if my patients have a hard time paying for it or to keep my visit charges down? A: If you want to provide a free service to your patients, you can. For instance, if cold packs during treatment are ALWAYS free and your financial policy explains that to be the case, you can choose to not charge for this service. Keep in mind, free is free, and that means that you don t bill health insurance, personal injury insurance, or anyone for this service, ever. If you want to provide a service for free to only certain, financially troubled, patients you should look to your hardship policy to go through the steps of verifying and documenting their hardship and allowing them your hardship sliding fee schedule on ALL services across the board. This will offer enough of a discount that your services should then be affordable without giving away any one service. (PS Check your third party payor contracts to ensure you can offer hardship schedules to your insured patients!) Want to know more about setting hardship fees in your office? Check out our Product of the Month section in this newsletter! your patient s out of pocket responsibility changes, they may become skeptical as to why. You and your team members must be the experts in the office who are able to quickly and confidently explain this to help the patient understand. The laws that govern your fees are often confusing, even for providers and team members; so, you can imagine how confusing they are for patients. Imagine the following scenario: It is the second week in November. Bettye Blue Cross presents to your office and insurance verification procedures have discovered she has 12 medically necessary chiropractic visits available on her plan. Her plan and deductible runs on a calendar year, and your expert verification has determined that 4 visits were used already at another chiropractor s office during this benefit period. Bettye now has 8 visits available to her until her benefits reset in January. You have performed your exam and have determined Bettye will need 18 visits of active treatment for her acute condition. After your Financial Report of Findings, Bettye has determined she would like to pay at the time of each service for her care. Her account is set up to process your BCBS fee schedule, and she has a $20 copay. Bettye has received care and has just completed her 8th visit. The front desk CA is aware that her benefits are now consumed, but she has approximately 10 more visits to go and it is only the second or third week in December. The conversation should go like this: FD CA: Bettye, remember when during your Financial Report of Findings with Sue, she mentioned your insurance company was going to assist you with paying for 8 more visits this year? Then she told you about ChiroHealthUSA and how our doctor is a participant in this plan? We are at that point where your carrier expects you to cover the remainder of the visits this calendar year, so I want to reiterate how important it will be to get started with ChiroHealthUSA, or CHUSA as we call it. To remind you, for that $39 annual fee, you ll have access to our discounted fee for folks like you who are under-insured, meaning that your insurance didn t cover all the visits necessary. Rest assured, we will begin to resubmit your insurance for any medically necessary care as soon as those benefits reset. Our regular fee for the service you have been receiving is $112. The discount you will get during the rest of this month will be $53 making your fee only $64 for these few visits we need to get in through the end of December. Bettye: Wow, that s a big discount. What has my insurance been paying? FD CA: We are in contract with your insurance company, so we have agreed to give them a discount as well. On the $112 actual fee we charge, our agreement is to accept the allowance of $72. We know you don t have too much control over the insurance you have, and with them no longer contributing, due to exhausting your annual benefits, we wanted to make sure that our patients got the best discount we can legally give them, so we have set up our fees

3 with ChiroHealthUSA (or whichever DMPO) to assist those like you who are expected to pay out of pocket. Bettye: Ok, I knew I didn t have many visits left that were covered this year. Do you think that I can expect BCBS to start paying in January if I m not finished with my treatment? FD CA: Absolutely. As long as you are still in Active Treatment for their definition of medically necessary care, they will consider your bills towards those allowed number of visits for next year, after meeting any deductible due. While an ideal scenario would have been handling this at the Financial Report of Findings (FROF), thus allowing care to simply continue as needed, at least making sure it s resolved BEFORE you begin cash related care ensures your patient gets the care they need. You must make sure your patient understands your actual fee, and any discounts they are entitled to receive, regardless of which fee structure they are on at the time. If you simply say it s $64 today and collect payment, they may get confused at a circumstance that happens down the road. Imagine Bettye gets into a car accident and her Med-Pay or PIP is being charged $112 for services. If you have never had a conversation clarifying your ACTUAL fees, she may get the impression you are overcharging her auto insurance company. Stay on top of patient education in this and all areas. The more information and understanding your patients have, the more likely it is that no problems or confusion will arise! The Compliance Corner Discounts, Discounts, Discounts At KMCU, we get many calls from providers who are struggling to make care affordable for their uninsured and underinsured patients. Many providers admit to capped fees for all treatment services during a visit, discounts higher than the federally allowed 5-15% for time of service payment, and to giving away exams, x-rays and therapies. While we firmly believe you should always charge and get paid fairly for the services you provide, we also understand the need to find a happy place where you don t have to turn away patients and you can still make a living for the care you provide. Keep in mind, there are many laws and regulations concerning your fee structure, and you don t want to be caught unintentionally violating these rules. There are many things to keep in mind as you create and use your fee structures in your office. Federal Insurance: Practices that routinely discount or provide services for free, outside of documented financial hardship, are in violation of the Patient Solicitation Anti-Inducement Provision Section 1128A of the Social Security Act. This act provides for the imposition of civil monetary penalties against any person who offers or transfers to a Medicare or Medicaid beneficiary (and any federally funded insurance payor) any remuneration that the person knows or should know is likely to influence the beneficiary s selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services and may be liable for civil money penalties of up to $10,000 for each wrongful act. Remuneration includes, without limitation, waivers of copayments and deductible amounts (or any part thereof) and transfers of items or services for free or for other than fair market value. This means you may not routinely discount statutorily non-covered services, such as exams, x-rays, therapies and durable medical equipment. It can be seen as an inducement to get a patient in to your office, in order to bill for the covered service, Chiropractic Manipulative Treatment. Dual Fee Schedules: Dual fees schedules, (charging more to insurance companies than you do to your cash patients) are illegal in most states and often violate provider agreements. Offering discounts that do not fall into one of Medicare s safe harbors is absolutely a violation of federal regulations in EVERY state. The OIG allows for a Time of Service discount from 5-15% which should reflect your actual savings in bookkeeping costs, but if you are discounting more than this amount, you may have a dual fee schedule. Keep in mind that Time of Service means the patient pays on the day the services are rendered, so this would not apply to patients on pay-plans when they are paying toward charges that are in arrears. Capped Fees: If you provide a patient with any needed services for a capped fee you could be in violation of the laws that govern fee schedules. A capped fee is often substantially discounted from what insurance companies are being billed per service. If you bill per service to the insurance company, you must do the same for your uninsured or underinsured patient, unless you have set up that type of legal cash fee structure with a DMPO. It is the recommendation of KMC University that providers join a Discount Medical Plan Organization (DMPO) such as ChiroHealthUSA ( The reason is that we believe it is the easiest, simplest and most compliant way to offer discounts. ChiroHealthUSA is not a Time of Service Discount, but a network contract discount. Chiro- HealthUSA patients are not required to make payment at the time of service to receive the CHUSA discounts. Medicare and other federally insured patients (underinsured) and cash patients (uninsured) may join this DMPO to become eligible for a legally discounted fee schedule offered through the network for their non-covered services. The good news is YOU CAN offer discounts; just make sure you have the best structure in place to avoid any violations!

4 The Reimbursement Room PQRS 1 time or 1.5%; You Decide Are you in on PQRS? Many doctors decided they would rather take the reimbursement penalty in 2015 than have to bother with the reporting hassle of PQRS. While we think this is a perfectly fine stance, there is some good news to those who just can t imagine taking on PQRS training and reporting. A provider only needs to report ONE measure on ONE patient in 2013 to be exempt from the 1.5% reimbursement penalty in The premise behind PQRS is that you will begin reporting on all of your Medicare patients, but if you find that you can t work it in to your procedures right away, you can still avoid the penalty. Submit one accepted claim to Medicare and you will be exempt. Pay close attention to your EOBs, making sure your claim is accepted by Medicare. Exclusion Criteria for Individual Eligible professionals per CMS: An individual eligible professional will meet the criteria for satisfactory reporting to avoid the 2015 payment adjustment if the eligible professional reports at least 1 valid Measure via Claims, Registry, Qualified EHR or 1 valid Measure Group via Claims or Registry on 1 eligible Med. Part B Patient. However, we strongly encourage eligible professionals and group practices to report on as many applicable patients as possible. In summary, eligible professionals and group practices have 3 options for meeting the criteria for satisfactory reporting for the 2015 PQRS payment adjustment: Meet the criteria for the 2013 PQRS incentive; Report 1 applicable measure for one eligible Patient. Elect to be analyzed under the administrative claims-based reporting mechanism. Breaking News Important Decision Regarding Mechanical Traction (as released by ACA) A recent decision by the US District Court of the District of Rhode Island may have significant implications for doctors of chiropractic (DCs) across the country who bill for mechanical traction. In 2009, Blue Cross Blue Shield Rhode Island (BCBS RI) sued two providers in state court for allegedly fraudulently billing intersegmental traction as mechanical traction, CPT code Attorneys for the providers were able to successfully move the case to federal court where the judge in the case, Senior Judge Ronald R. Lagueux, found that the fraud claims were completely preempted by the Employee Retirement Income Security Act (ERISA). At the conclusion of the resulting bench trial, Judge Lagueux found that the services were correctly billed by the providers as mechanical traction and rejected BCBS RI s findings of fraudulent billing, stating that the plaintiffs did no wrong. The case was argued on behalf of the plaintiffs by D. Brian Hufford of Pomerantz, Grossman, Hufford, Dahlstrom & Gross, LLP (Pomerantz), the same firm representing ACA and other plaintiffs in class action suits against United Healthcare/Optum and Cigna and ASHN. While this lawsuit was not the result of any action by ACA, it has been ACA s policy for over a decade that Roller table type traction normally meets the requirement of autotraction, the use of the body s own weight to create the force and therefore is properly coded, as the doctors in question had and the court supported, with While doctors of chiropractic should always verify coverage to determine each payer s specific reimbursement policy, this decision may have an impact on providers who have had reimbursement for traction recouped (Note: This decision references only intersegmental or roller table type traction, not non-surgical spinal decompression). DCs who have experienced this type of recoupment by any payer are encouraged to contact Mr. Hufford directly at: D. Brian Hufford Pomerantz Grossman Hufford Dahlstrom & Gross LLP 600 Third Avenue New York, NY (fax) dbhufford@pomlaw.com

5 ST. LOUIS, MO - SEPTEMBER 20-21, 2013 ONE WEEKEND, MASSIVE RESULTS! 72% 87% 60% of DCs surveyed don t have an OIG Compliance Program in place... Get yours ready in just one weekend. of DCs surveyed admitted that being compliant will bring them peace of mind... Get a refreshed sense of purpose in just one weekend. of CAs admitted they feel unprepared for the job being asked of them... Yours WILL be prepared after just one weekend. Break the routines and habits that are keeping your office away from compliance and financial ease... In just one weekend! Reimbursement and Compliance issues can drag your practice down and frustrate you into throwing up your hands. Spend the weekend with us and you will: Leave with all the components and particulars of your compliance manual, ready to implement on Monday morning. Be immersed with your team in an engaging and insightful workshop, packed with a wealth of information, all of which is immediately useful. Have clarity on the rules of healthcare compliance that apply to you and your office, right now. Learn strategies and tactics that will increase reimbursement right away. Attendees report an average increase in excess of $30,000. Return to your practice with a renewed peace of mind, ready to practice on your terms with no fear! READY TO REGISTER? Use the registration form on the next page. HAVE QUESTIONS? Call us at TEAM KMC Ext. 105 NEED MORE INFORMATION TO REVIEW? Visit

6 HANDS-ON LAB REGISTRATION FORM $997 Registered by August 30 $1,197 Registered after August 30 Registration fee includes up to three people from your office. Name Name Name Name (Additional Attendee) Name (Additional Attendee) ATTENDANCE FEE CALCULATION: Registration fee + Additional $129 each = Total Attendance Fee Payment Information Method of Payment Name (As appears on Credit Card) Credit Card Number VISA MASTERCARD AMEX Office Name Billing Address Expiration Date Credit Card Validation (CCV) City State ZIP I authorize Kathy Mills Chang, Inc. to charge my credit card the amount indicated in the TOTAL ATTENDANCE FEE field above. Phone Number Address Signature Yes, add me to the KMCU mailing list! Product of the Month Setting Hardship Fees in Your Office $120 OFF!!! NOW JUST $129! USE CODE AUGPOM AT CHECKOUT Does your fee system have one loose end offering discounted fees to patients who claim financial hardship without verification? Are you allowing this without a written policy? Dealing with individual patients financial need while providing them with needed treatment can be tricky. Set up a compliant Hardship Fee Schedule, so your patients can appropriately qualify for these discounts for a period of time. You will work through the step by step guide to establish a Financial Hardship policy for eligible patients utilizing a sliding scale and the steps necessary for proper verification. Hurry! Offer expires 8/31/13 Get the Product of the Month here:

7 Preferred Partner s Corner Maximum Postural Integrity The feet play a vital role in establishing maximum postural integrity throughout the body and thus their importance in maintaining the longevity of an adjustment must not be minimized or ignored. Because the feet are the foundation of the body, any imbalance in them creates a ripple effect, leading to a series of pains and complications throughout the kinetic chain. To maintain the integrity of the kinetic chain for as long as possible following an adjustment, balancing the feet must be a top priority. Along with being the foundation of the kinetic chain, the feet are also the first line of defense against the impact force created by the simple task of walking. When a 100-pound person walks a mile each foot absorbs 25-tons of force. The force created by walking can be felt in every joint and muscle in the body and can even jolt the brain up to a half a millimeter. Such a force can cause persistently painful and stiff joints, particularly in those with existing degenerative conditions. Foot Levelers has always recognized the importance of the feet in maintaining the value of an adjustment and reducing the skeletal effects of activities such as walking and running. Working with chiropractic, their Stabilizing Orthotics help to balance the body s foundation, thereby working to correct knee rotation, pelvic tilt, and shoulder drop and alleviate the accompanying pain and complications. With the kinetic chain corrected and pain and discomfort minimized, the time required between adjustments is often increased. Among other patented technologies, Stabilizing Orthotics features a viscoelastic material, Zorbacel, which helps reduce the impact force on the skeletal system. Foot Levelers individually designed Stabilizing Orthotics are purposed to help improve overall health by balancing the body. To learn more about Foot Levelers individually designed Stabilizing Orthotics, visit Next Live AnswerCall Four Critical Fee Schedule Policies to Have in Writing Now offered at two different times: AUGUST 13 1:00 PM ET and 9:00 PM ET Next Live Webinar Foundational Fee Schedule Fundamentals AUGUST 20-1:00 PM ET CLICK HERE TO REGISTER THESE MONTHLY WEBINARS AND ANSWERCALLS ARE PART OF THE KMC COMMUNITY COLLEGE MEMBERSHIP! CALL US FOR MORE INFO ON HOW TO JOIN! Helping Chiropractors make and keep more money.