By now, you have likely heard about the controversial report that the Office of the Inspector General (OIG) released in May 2009. One of the most alarming aspects of this new report is its booming title: "Inappropriate Medicare Payments for Chiropractic Services." The timing of the report's release (at the cusp of national health care reform) is equally intriguing.My firm stance is that the results in this report would have been considerably more favorable if the chiropractic physicians studied were using electronic health records (EHRs) and digital documentation that could have guided them toward compliant Medicare notes. Why wasn't that the case? Read on.
In comparing the infamous 2005 OIG report to the new 2009 report, there is significant improvement in the field's documentation. However, the most glaring criticism of the results should be this: The data used in the 2009 report were chiropractic records obtained from services provided in 2006. The profession became aware of documentation deficiencies in June 2005, and it took well over a year before information, in the form of classes, seminars, educational articles and direct communication, filtered across the profession's landscape. Sure, there were education efforts prior to the report in 2005, but the dedicated push from state associations, colleges and national organizations understandably took place after the report pointed to specific errors and omissions.
These organizations had to formulate mass learning strategies and systematically educate our fellow doctors to be aware of and address deficiencies within Medicare documentation guidelines. Then, the real challenge was to get field doctors to participate in the necessary educational forums. Thus, it took a few years to accomplish overall awareness, understanding and participation on the part of the profession.
The deceiving title of the 2009 report is not just in the bold statement that there are inappropriate payments for chiropractic services. The fact that "2009" is imprinted on the report gives readers the impression that four years passed between the 2005 and the 2009 report. In fact, the data and office visits analyzed in the 2009 report were between seven and 18 months after the release of the 2005 report; certainly not four years, as the title implies.
It would not seem logical that the 2006 documentation the OIG reviewed for the 2009 report would have changed significantly from the 2005 report, since there was little time to change procedures and educate doctors prior to the 2006 study sample. Consider for a moment what the data would have looked like if it were actually taken from office visits in 2008 versus 2006. I believe the error rates would have been dramatically improved due to education as well as implementation of current technologies.
However, even in just one year of educating a portion of the profession (2005 to 2006), results did improve significantly. Yet, the real bulk of the educational efforts to the profession occurred in 2007 and 2008. Upon adding up all of the documentation deficiencies and errors described in the 2005 report, 94 percent of the cases reviewed had a problem. The 2009 report revealed 47 percent had an error or deficiency in the notes. This demonstrates that errors and deficiencies were basically cut in half in less than one year following release of the 2005 report. If the data had been analyzed a full two years later - well, you can come to your own conclusions.
While reviewing the 2009 report content, I observed a few other glaring sticky points. In most cases, accidentally omitted documentation led to Medicare declaring visits as "maintenance" and thus nonpayable. The truth and reality is that most of those were not maintenance visits, but due to missing documentation; the reviewer was required to label them "maintenance according to the Medicare policy manual." In the end, the almighty dollar spoke the loudest. The amount of documentation Medicare requires takes a great deal of time to complete for each patient. If these doctors had technology to guide them through the required data, the documentation process would be streamlined, and compliance facilitated.
Also of note is that the study only reviewed 188 claims. You read that correctly - 188 claims. This is an absurdly small sample size, extrapolated and flatly applied across the entire industry. Is the OIG picking on us? Not likely. Practitioners aren't the ones who are paying the greatest price - patients are. If Medicare dictates that certain criteria are documented and completed, and a DC accidentally overlooks one of those, a reviewer will deny the patient's claim and classify the visit as maintenance. This is ruefully unfair to the patient who has a legitimate clinical issue, and it also puts the claim squarely into that 47 percent error and omission category.
Medicare has its rules and policies. Whether a visit is maintenance according to a definition or whether the patient truly had clinical issue with loss of function and benefited from chiropractic care makes no difference to policy workers. They're just reviewing for compliance. Now that these two studies are behind us (and others are certainly on the way), how do we resolve this difference from the clinical truth?
You know what the answer is: technology. With the required treatment plans, goals, demonstrated functional improvement with measurable progress, and a whole host of other history, exacerbation and pain-assessment criteria, the DC cannot feasibly record complete information in a busy practice within the old travel-card model. Even dictation has its downfalls when it comes to accurately recalling each line item or remembering all the criteria to record. The technology of a true electronic health record can guide you to include all of the necessary components, create treatment plans quickly, and allow easy monitoring of activities of daily living and the goals associated with them. This is truly a better way you can efficiently manage the web of requirements in today's health care delivery model.
That said, the future health care delivery model relies even more on technology. Indicators from surveys of chiropractic doctors, government design within the Department of Health and Human Services, and the White House push toward national health care reform prove it. I surveyed chiropractic attendees at three recent live educational seminars, as well as four Webinars for which I was the speaker on the topic of documentation, EHRs, and the economic stimulus package. Findings were consistent across the board: More doctors had recently adopted EHR technology than had not. Of all the doctors in the room, 76 percent had already adopted or were planning to adopt it within one year. An additional 14 percent were planning to adopt EHR within two years. All of this, yet less than 12 percent of the profession has implemented a true interoperable EHR? It's clear that the education of DCs must now include differentiating between an actual EHR and a digital note generator.
The federal government is not providing stimulus money for a digital note generator; they are providing incentive payments to adopt an EHR system. The EHR will need to communicate with other providers and import clinically significant health information when needed and approved by the patient. Many doctors with whom I have consulted had previously made major mistakes in purchasing a documentation note tool, thinking it would meet the requirements for stimulus money or satisfy a state law mandating the use of a certified EHR before a predetermined deadline. This was nothing but wasted money spent on deficient pseudo-technology. It's still happening. And that hurts. True EHR technology is not only the key to improved patient care and better office efficiencies, but also positions DCs to quickly pass audits because complete information is readily accessible.
In upcoming articles. I will share what meaningful use and interoperability mean so you can potentially qualify for federal stimulus money and meet the requirements of state laws as more regional health information exchanges are developed. For example, in the very near future, your EHR, must be able to connect with other digital systems such as digital X-ray and inclinometer devices, as well as to the outside world to access MRI and specialist reports or medications your patients are taking.
Awareness of the benefits of technology is the first step. Now that we're aware, we must adopt it in the correct manner, with the right EHR resources, to facilitate compliance and eliminate unnecessary mistakes that unjustly give the industry a black eye. It may sound a little overwhelming, but trust me, it's not nearly as overwhelming as failing an audit or being included among 188 studied claims that reflect on the entire profession.
However, if you obtain technology only for the sake of getting stimulus money, you are totally missing the boat. Technology positions you to enhance your quality of care and assess all relevant information about a particular patient. This will improve your clinical decision-making at critical junctures. Second, technology creates efficiencies in your office in the way of patient flow, management, guidance and reminders, and alerts for options and avoidance of mistakes in coding or documentation guidelines. These are the benefits you receive as a health care provider. Your patients also realize the benefits of improved case management and comprehensive care due to your awareness of their whole health picture.
Technology is the only way we can genuinely reform the American health care system. Adopting the right technology with true EHR capabilities is your responsibility. Are we going to advance our profession and promote the skills and talents of the chiropractic physicians in this country, or are we going to wallow in the past and sit on the sidelines, giving the impression that we are unfit, unwilling and ill-equipped to be an essential part of the American health care system? The train is moving, so let's get on board and elevate the profession to its rightful place.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.