How to Retain More of Your Medicare Money, Part 5

Protecting Yourself

By Ronald Short, DC, MCS-P

This five-part series, of which this is the final installment, is designed to give you the information you need to protect yourself from some of the most common Medicare errors.

Part 1 discussed the various ways Medicare could review your records and deny or demand refund of your payments. Part 2 discussed how to use the treatment plan to prove medical necessity. Part 3 discussed the proper use of the Advanced Beneficiary Notice of Noncoverage to inform the patient and preserve your rights to collect your fees. And in Part 4, the appeal process was detailed. Now let's take a look at some of the best ways to protect yourself and your practice when it comes to Medicare.

Medicare Protocols

The first step to protecting yourself is to learn the laws, rules and regulations established by Medicare and incorporate them into the protocols of your practice. Medicare has detailed these procedures in various online manuals and publications. CMS and OIG have issued reports that suggest chiropractors are less than competent at documenting medical necessity. This means we need to do it better, cleaner and more accurately than anyone else. A Medicare patient is different from any other patient and needs to be treated according to Medicare laws, rules and regulations. Documenting medical necessity to Medicare's standards will help you avoid many problems.

ABN Update: The New GX Modifier On April 5, 2010, Medicare implemented a new GX modifier. The GX modifier is to be used when you voluntarily use the Advanced Beneficiary Notice of Noncoverage (ABN; see part 3 for more information) to notify a patient that they are financially responsible for a non-covered service. Use the GY modifier to indicate that the service is not covered; then use the GX modifier to indicate that the ABN was given to the patient. The GX modifier is to be used only with non-covered services. Medicare has also redefined the GA modifier to mean: "Waiver of Liability Statement issued as Required by Payer Policy." The GA modifier is only to be used for covered services, which for a chiropractor are the procedure codes 98940, 98941 and 98942.

Self-Audits

Providers may perform self-audits to identify any coding errors or overpayments. In fact, Medicare expects that you will do this on a regular basis. These overpayments are required to be refunded to the Medicare carrier or MAC.

There are two problems with this procedure. The first is that Medicare's policy maintains the following: "The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims." In simple terms, if you refund that money, you may still be fined or prosecuted. The second problem is: "Voluntary refund checks payable to the Medicare program cannot be returned, regardless of the amount of the refund. If you need to refund Medicare, please verify you are sending the correct amount."

These two policies do not really provide an incentive to the provider to voluntarily refund any overpayments.

The Gold Standard - The Office Compliance Program

In October 2000, the Office of Inspector General of Health and Human Services published guidelines in the Federal Register for the development of a compliance program for the small to medium practice. The office compliance program is designed to cover all government programs to which you are subject, such as CMS, OIG, HIPAA, CLIA, OSHA, the anti-kickback laws and the Stark laws. According to the OIG, the seven essential elements/actions required of an effective compliance program are:

1. Implement written policies.
2. Designate a compliance officer.
3. Conduct comprehensive training and education of all staff.
4. Develop accessible lines of communication.
5. Conduct internal monitoring and auditing.
6. Enforce standards through well-publicized disciplinary guidelines.
7. Respond promptly to detected offenses and undertake corrective action.

The advantage of having an effective compliance program in place is that virtually every federal agency considers the program to be a mitigating circumstance to the imposition of fines and penalties. This even extends to federal sentencing guidelines.

The first part of establishing a compliance program is to determine what deficiencies exist in your office procedures. The best way to accomplish this is to have an objective third party who is familiar with chiropractic and trained in the intricacies of the compliance issues conduct a detailed audit of your facilities and procedures. This audit should include an on-site inspection and a review of randomly selected patient charts.

Once the deficiencies are identified, a plan should be developed to assist and guide you in correcting these deficiencies. The office compliance program will then provide you with the tools necessary to systematically bring your office into compliance with all federal laws, rules and regulations. As additional deficiencies are identified through internal auditing and monitoring, you will be able to respond appropriately.

Compliance programs are common in the medical world and are usually handled by in-house compliance officers specially trained and certified for the task. This certification is offered through medical compliance training and is approved by both the American Academy of Professional Coders and the Professional Association of Health Care Office Managers.

While having specially trained and certified personal on staff has proven too costly for most chiropractic offices, an alternative is now available. For the first time, this training is available to chiropractors with an additional eight hours leading to a Medical Compliance Specialist certification with Chiropractic Proficiency. This is the objective third party you want assisting you with the development of your office compliance program.

Final Thoughts

When a Medicare patient is not treated in compliance with the laws, rules, and regulations of Medicare, you, the doctor, are placed at risk. The least that can happen is that you will be required to refund money that Medicare reviewers identify as "overpayments." You could also be at risk of fines, penalties and even jail in extreme cases.

Modifying your office protocols to comply with Medicare laws, rules and regulations is the least you should do. Ideally, you should implement an office compliance program to ensure your procedures are in line with all applicable laws, rules and regulations.

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Dr. Ron Short is a 1985 graduate of Palmer College of Chiropractic. The author of Medicare for Chiropractors, Dr. Short is a certified insurance consultant, peer-review specialist and medical compliance specialist. Direct questions and comments to Dr. Short via e-mail ( ); interested parties can also e-mail him and request a free packet of additional information regarding Medicare reviews and treatment plans, along with instructions on completing the ABN, including how to compute cost estimates.