Dr. Brian’s Blog on Chiropractic Office Billing, Software, and Profitability

Dr. Matthew Singer
Chiropractor at Chiropractic Wellness Solutions in Wayne, New Jersey
Graduate of Life University School of Chiropractic (2001-2005)

Pompa Health Solutions Provides State-of-the-Art Spinal Corrective Care for neck & back trauma from car accidents, work related injuries, whiplash & other spinal related injuries & diagnosis. Dr. Pompa is globally renowned for fighting degenerative disease. His neurotoxic, nutritional & detoxification protocols are now used by rapidly growing number (currently > 200) of Doctors around the country. As a sought-after doctor & educator for the treatment of such neurotoxic-mediated illnesses as autism, chronic fatigue syndrome, weight loss resistance, & fibromialgia, his teaching is transforming the lives of thousands around the world. His philosophy is founded upon natural solutions utilizing the latest research; his chiropractic care utilizes NASA technology. His detoxification & diet protocols have brought healing to the seemingly incurable, & have been replicated by other physicians he teaches across the nation. Dr. Pompa & his wife, Merily, are parents of 5 children & reside near Pittsburgh, PA. He currently is publishing several books one on “new millennium” diseases and disorders.
Pompa Health Solutions

With the help of membership, ANJC just completed statewide petitions directed to DOBI with great success. As planned this allows us to move to the next and most important step.

Identifying Specific Insurance Carriers:

ANJC is presently attempting to collate information regarding potential unfair claim settlement procedures by insurance carriers. In this regard, we are reaching out to membership with a request for information to assist in this project.

Please review your practice records and provide the following info to ANJC HQ by either:

* Fax: 908.722.5677
* Email: sig@anjc.info
* Mail: ANJC, 3121 Rte 22 East, Ste 302, Branchburg, NJ 08876

Out of Network Providers:

1. Explanation of Benefit Forms denying reimbursement to chiropractors for Evaluation and Management Services (CPTs 99201-99245) on the same day as a chiropractic manipulative treatment even when the E&M is billed with a modifier -25.

2. Explanation of Benefit Forms denying reimbursement to chiropractors for Evaluation and Management Services (CPTs 99201-99245) as a stand-alone service when no CMT is performed.

3. Explanation of Benefit Forms denying reimbursement to chiropractors for physical modalities or active therapy (CPTs 97010 to 97535) on the same day as a chiropractic manipulative treatment.

4. Any EOB form which states an E&M or physical modality or therapy is outside the chiropractic scope of practice or that this provider cannot perform such a service.

In-Network Providers:

1. Explanation of Benefit Forms denying reimbursement to chiropractors for Evaluation and Management Services (CPTs 99201-99245) as a stand-alone service when no CMT is performed.

2. Any EOB form which states an E&M or physical modality or therapy is outside the chiropractic scope of practice or that this provider cannot perform such a service.

Please redact (cross out) all of the private patient health information on all documents you submit so that you are in compliance with HIPAA.

Thanks in advance for you assistance,

Respectfully submitted,

Sigmund Miller, DC, FICC

All the best,

Sigmund Miller, DC, FICC - Executive Director
Association of New Jersey Chiropractors
Expertise. Answers. Results.
3121 Route 22 East, Suite 302, Branchburg, NJ 08876
908.722.5678 | 908.722.5677 - fax
www.anjc.info

In June, the Chiropractic Office Billing Precision Index (BPI) gained 4.2 points above its May mark - making up all of the lost ground in May and outperforming April. Overall, June BPI reached 17.6 outperforming the national average of 17.7 by 0.1, and 2.1 points away from its best record of 15.5 in March of 2008.

Breaking the pattern established in April and confirmed in May, the June index, replaced two participants, namely, GEICO and Blue Cross Blue Shield South Carolina, with Blue Cross Blue Shield Michigan and State Faarm - a veteran and a new index participant, returning at 14.9 and debuting 41.1, in the fifth and ninth place respectively. Both GEICO and Blue Cross Blue Shield South Carolina first gained their participation in May, only to be replaced in June. Medicare South Carolina managed to keep its participation in spite of losing score from 39.2 to 46.1 and dropping from eighth down to tenth position. Note that BCBS Illinois not only maintained its top placement but also improved the score from 4.5 up to 2.4, while Medicare Illinois and Aetna returned to their traditional second and third placed, pushing back down United Healthcare and CIGNA.

Billing Precision Index 17.6 - June 2008

1. Blue Cross Blue Shield Illinois 2.4
2. Medicare Illinois 10.5
3. Aetna 11.8
4. United Healthcare 13.3
5. Blue Cross Blue Shield Michigan 14.9
6. CIGNA 15.4
7. Blue Cross Blue Shield New Jersey 20.6
8. Medicare New Jersey 27
9. State Faarm 41.1 (new participant)
10. Medicare South Carolina 46.1

BPI is an important billing performance characteristic because it approximates the proportion of claims that are never paid. BPI = 17.6 means that the average of ten top performing payers, used by the patients of Billing Precision providers, reached 17.6% of Accounts Receivable beyond 120 days.

This welcome improvement comes at the same time as the nation’s doctors are fighting to hold off a ten percent fee cut in Medicare payments that was slated to kick in on July 1. The Congress is given extra time to prevent the reduction by simply holding off the processing of the claims for the first ten days of July for July dates of service. If successful, this delay should have low impact on providers’ overall monthly cash flow because Medicare claim payments take 14 days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before June 30, 2008, are processed and paid under normal procedures.

Chiropractic office managers use the rule-based index to benchmark their billing performance and guide its improvement over time. Rule-based benchmarking also allows for the identification of elite payers, those that perform best in comparison to every payer in the country, as shown by the index-driven ranking.

Know any health care providers who complain about shrinking insurance payments and increasing audit risk? Help them learn winning Internet strategies for the modern payer-provider conflict by steering them to Billing Precision - The CNS for the Chiropractic Office, home of Practicing Profitability - Billing Network Effect for Revenue Cycle Control in Healthcare Clinics and Chiropractic Offices: Collections, Audit Risk, SOAP Notes, Scheduling, Care Plans, and Coding” book by Yuval Lirov, PhD and inventor of patents in artificial intelligence and computer security.

Article Source: http://EzineArticles.com/?expert=Yuval_Lirov

A recent AMA study found that doctors spend 14 percent of the fees they receive from insurance companies and Medicare on the process of collecting those fees, adding more than $200 billion (about ten percent) a year to the nation’s healthcare costs [Lisa Girion, 2008]. Sadly, about 30 percent of over 5 billion claims generated annually, are rejected, and surprisingly, only 50 percent of the rejected claims are ever resubmitted [Walker et al, 2004]. Note that physicians are giving up this revenue in addition to losing revenue because of the annual cuts of allowed fees. (Since 2000, health insurance premiums increased by 73 percent compared to cumulative increases in inflation and wages of about 15 percent. Yet physician’s inflation-adjusted incomes dropped by 7 percent from 1995 to 2003 [Herzlinger, 2007].)

Why are the costs of collecting the earned fees so high and why, adding insult to injury, do providers often skip resubmitting rejected claims?

Insurance companies would like us to think that billing costs are high because of inefficiencies, and they are quick to blame the doctors for them [Lisa Girion, 2008]: UnitedHealthcare spokesman Gregory Thompson said, “Data show there is often a significant lag time between when services are provided and physician claims are submitted.” Another often cited reason for delays and underpayments is the time that doctors take to resubmit claims or provide additional information upon insurer’s request.

But a recent AMA’s “report card” shows a wide variance between various payers in terms of payment accuracy and timeliness, ranging from 61 to 87 percent of the time [Bergen 2008]. Such a wide variance in payment accuracy and timeliness across the payers contradicts the “physician’s inefficiency” theory. If this theory was true, then, the more efficient physicians should be losing less money on rejections than others, uniformly across all payers. Conversely, since the largest insurance companies are present in most states and are exposed to vast majority of physicians and their claim delays, the differences in underpayments and denials must be attributed first of all to the differences in payer’s business strategies and processes and not - to inefficiencies in the provider’s office.

For instance, a simple calculation following an example in [Walker et al, 2004] shows that systematic claim denial is beneficial to payers when the cost of rework outweighs the benefit of resubmitting the claim. Let us assume $130 for initial charge, $55 - allowed amount, $29 - service cost, $6 - claim preparation and mail, and $25 - claim rework cost. If the claim is paid in full after contractual adjustment ($75), practice total costs would add to $35 and income - $20. But if the payer denies a part of the claim, say, $30, then the provider has a choice between leaving it alone and losing $10 on the entire incident or reworking it and then taking a chance of losing even more - $35, in case of a repeat denial, or losing $5 if the payer chooses to pay the previously denied part of the claim.

In other words, depending on the claim rework costs, denial amount, and repeat denial odds or claim rework efficacy, it may be in the provider’s best interest to minimize losses by abandoning the denied claim instead of working the denial. Therefore, a rational payer will deny a higher number of claims, counting on the good business sense of the rational provider who will only rework a small subset of the denied claims, specifically those claims that can be justified with a quick cost-benefit calculation such as the aforementioned example. Such rational payer’s behavior explains the AMA findings much better than any inefficiency on the provider’s side.

To justify rework of every denial and to eliminate a financial incentive for payers to deny claims, providers need systems with low claim rework costs and high rework efficacy. To “educate and empower physicians so they are no longer at the mercy of a chaotic payment system that takes countless hours away from patient care,” (William Dolan, MD, member of AMA board [Japsen, 2008]) requires a leveled playing field for both providers and payers. And leveling the playing field with the payers requires equal footing in terms of strategies, processes, and resources [Lirov, 2007].

References:
1. Bergen, Jane M. von, AMA issues report card on health insurers, Philadelphia Inquirer, June 16, 2008
2. Girion, Lisa, “Failings by insurers and Medicare add more than $200 billion a year to the nation’s healthcare tab, report says,” Los Angeles Times, June 17, 2008.
3. Herzlinger, Regina, “Who Killed Health Care? America’s $2 Trillion Medical Problem - and the Consumer-Driven Cure,” McGraw Hill, 2007.
4. Japsen, Bruce, “AMA to rate business practices of health plans,” Chicago Tribune, June 16, 2008
5. Lirov, Yuval, Practicing Profitability - Billing Network Effect for Revenue Cycle Control in Healthcare Clinics and Chiropractic Offices, Affinity Billing, New Jersey, 2007.
6. Walker, Deborah, Larch, Sara, and Woodcock, Elizabeth, The Physician Billing Process - Avoiding Potholes on the Road of Getting Paid, MGMA, 2004

Know of medical billing service providers or practice software vendors who complain about escalating competition, disloyal clients, or shrinking profit margins? Help them learn winning Internet strategies for modern practice management challenges by steering them to Vericle - All-in-One Billing and Practice Management Network, home of Practicing Profitability - Billing Network Effect for Revenue Cycle Control in Healthcare Clinics and Chiropractic Offices: Collections, Audit Risk, SOAP Notes, Scheduling, Care Plans, and Coding” book by Yuval Lirov, PhD and inventor of patents in artificial intelligence and computer security.

Article Source: http://EzineArticles.com/?expert=Yuval_Lirov

As you were previously notified, the New Jersey Supreme Court issued its decision in the extraspinal adjustment case of Bedford v. Riello on June 18, 2008, making it permissible again for New Jersey chiropractors to perform extraspinal manipulations on their patients provided that they document a causal nexus between a condition of the manipulated structure and a condition of the spine.

In this regard, chiropractors may now again bill for CPT 98943 (extra-spinal adjustment) provided that they meet the causal nexus requirement. In the near future, the ANJC will be presenting telephonic webinars as well as live presentations at regional meetings on how to properly determine and document a causal nexus to the spine, and it is imperative that all chiropractors attend at least one program to assist in ensuring your documentation supports your extraspinal billing.

As insurance carriers and their administrators may have reprogrammed their claim software or amended their claims policy to deny reimbursement for CPT 98943, the ANJC anticipates that it may take a period of time for insurers to reverse the denials to comply with the Supreme Court decision and start issuing payment. Thus, you may receive denials for your extra-spinal adjustments until the appropriate changes are made within the insurance carriers.

If you do receive a denial for reimbursement for CPT 98943, it is imperative that you appeal the denial. There are two possible routes that you must follow depending upon whether the denial is based on i) medical necessity grounds or ii) other grounds, as follows:

IF DENIED ON MEDICAL NECESSITY GROUNDS –
You must file an internal / external appeal by filing up to two internal appeals and a third external appeal by filling out the following forms:
One Internal Appeal Form: http://www.state.nj.us/dobi/chap352/352noticesf1.doc
Stage Two Internal Appeal Form: http://www.state.nj.us/dobi/chap352/352noticesf2.doc
Stage Three External Appeal Form: http://www.state.nj.us/dobi/chap352/352noticesf3.doc

You also have the right to file a complaint with the New Jersey Department of Banking and Insurance regarding the improper denial by filling out the following Complaint form:
DOBI On-Line Complaint Form: https://www6.state.nj.us/DOBI_UIC/UICPublicEntryServlet
DOBI Paper Complaint Form: http://www.state.nj.us/dobi/division_insurance/managedcare/mc_1complaints.doc

IF DENIED ON GROUNDS OTHER THAN LACK OF MEDICAL NECESSITY –
You must file at least one internal appeal and then may proceed to a major medical arbitration provided you meet the filing criteria for arbitration. The required forms may be obtained by clicking on the following links:
Major Medical Internal Appeal Form: http://www.state.nj.us/dobi/chap352/352genapplication.doc
Major Medical Arbitration Link: https://njpicpa.maximus.com/

You also have the right to file a complaint with the New Jersey Department of Banking and Insurance regarding the improper denial by filling out the following Managed Care Complaint form:
DOBI On-Line Complaint Form: https://www6.state.nj.us/DOBI_UIC/UICPublicEntryServlet
DOBI Paper Complaint Form: http://www.state.nj.us/dobi/division_insurance/managedcare/mc_1complaints.doc

The ANJC asks all members to carbon copy ANJC headquarters on all appeals and DOBI complaints filed regarding extraspinal adjustments so that it can track any patterns of improper denials and bring it to the attention of the carrier and DOBI. You may email your appeals / complaints to: sig@anjc.info or fax them to (908) 722-5677.

The ANJC plans on monitoring this situation closely to ensure all payers comply with the Supreme Court decision. Any improper denials will be met by immediate action by the ANJC but will require documentation of appeals and complaints by New Jersey chiropractors in order for us to properly protect the rights of chiropractors in this State. Thus, it is imperative that you appeal any CPT 98943 denials as well as exercise your right to complain to the Department of Banking and Insurance if improperly denied reimbursement. We thank you in advance for your cooperation.

Association of New Jersey Chiropractors,

Steven Clarke, DC,
President

Sigmund Miller, DC,
Executive Director

Jeffrey Randolph, Esq.
ANJC General Counsel

3121 Route 22 East, Suite 302, Branchburg, NJ 08876
908.722.5678 | 908.722.5677 - fax
www.anjc.info

BY TOM HESTER

Star-Ledger Staff New Jersey’s over 2,500 chiropractors are feeling relief after the state Supreme Court ruled yesterday that state law allows them to adjust a patient’s arms and legs when treating a problem related to the spine.

The justices, in a 4-2 decision, overturned an appeals court ruling that held the practice of chiropractic is limited to adjustments of the spinal column and that manipulation of other parts of the body could leave them open to negligence claims.

“Today’s decision, if I had to sum it up in a nutshell, put chiropractors back in the position where they were before the 2007 appeals court ruling,” John W. Leardi, the Lawrence-based attorney for the Association of New Jersey Chiropractors, said yesterday. “It restores their ability to practice as they had done for decades prior to last year’s decision.”

The ruling came in a malpractice case brought by Carol Bedford, 59, and her husband H. Paul Bedford of Brick against two Brick Township chiropractors, Anthony Riello and Peter Lowenstein.

Bedford contended she sustained torn cartilage in her left knee when the chiropractors adjusted it during treatment in 1999, and that she had to undergo two surgeries to attempt to correct the problem.

Between 1998 and 1999, Riello and Lowenstein treated Bedford at least 180 times, according to the court ruling. Bedford testified at trial that when Riello first handled her knee, she felt a pop and experienced serious pain.

The Bedfords’ attorney, Danielle Chandonnet, argued the law prohibits chiropractors from manipulating arms or legs, but a Superior Court judge in Toms River disagreed. The case went to a jury that found the doctors followed proper treatment procedures.

Full story

Link Press Release of of Supreme Court Decision

Sigmund Miller’s recording of the statewide Bedford Conference Call following the decision 

BY KATHLEEN HOPKINS
GANNETT NEW JERSEY

Posted by the Ocean County Observer on 10/23/07

TOMS RIVER — The state Supreme Court has agreed to hear an appeal of a lower-court decision out of Ocean County that has barred chiropractors statewide from performing procedures they had been doing for decades and are allowed to perform in 49 other states.

Among cases posted last week on the state judiciary’s Web site that the state’s highest court has agreed to hear was one brought by patient Carol Bedford against chiropractors Anthony L. Riello and Peter E. Lowenstein and Coastal Chiropractic, a Brick practice with which Riello is no longer affiliated.

A decision in April by a panel of judges with the Ap-pellate Division of state Superior Court ruled in the case that the state law governing chiropractic care limits chiropractors to performing adjustments of the spinal column. The ruling outlawed adjustments to extremities and other joints, which chiropractors had been doing for decades and are allowed to do in 49 other states.

The decision is not only impacting the businesses of many of the state’s 2,500 chiropractors, it is also affecting their patients who have come to rely on extremity adjustments but can no longer have the procedures done in the state, according to the Association of New Jersey Chiropractors.

Following the appellate court decision, the defendant chiropractors appealed, and the association filed a brief in support of the appeal. The Supreme Court in late September granted certification to hear the appeal.

“We are overjoyed, absolutely overjoyed,” said John W. Leardi, an attorney for the chiropractors association. “This is a very big first hurdle.

“In that only approximately 4 percent of petitions for certification are granted, this development is monumental,” he said.

“In order to convince the Supreme Court to review a particular matter, a party must demonstrate that the issues raised are of exceeding public importance,” he said. “The ANJC provided the court with two crucial perspectives that would have otherwise gone unstated: that of chiropractors throughout the state who have been irreparably harmed financially and, more importantly, that of chiropractic patients throughout the state who have been robbed of a safe, effective and relatively inexpensive treatment choice.”

Since the appellate decision, the association had collected signatures of more than 30,000 patients supporting the practice of extremity adjustments, Leardi said.

The chiropractors association has been addressing the lower-court ruling on two fronts: supporting the appeal and also lobbying to change the law to allow for extremity adjustments. A statute that would do that was passed in the Assembly on June 21, the Legislature’s last day in session before the summer break. But the Senate sent it to its Commerce Committee, where it still sits.

Full article

Supreme Court Decision press release 

The New Jersey Supreme Court issued its decision in the extraspinal adjustment case of Bedford v. Riello today at 10:00am. The Court, with two justices dissenting, held that the chiropractic scope regulations “permit manipulation of articulations beyond those of the spine when there is a causal nexus between a condition of the manipulated structure and a condition of the spine.” The Court further held that, “Whether adjustment of a particular portion of the body is permissible as a “related structure” under the rule must be determined and demonstrated by the practitioner on a case-by-case basis, focusing on whether a condition to the adjusted structure bears a causal relationship to a condition of the spine.”

This is a resounding victory for all chiropractors in New Jersey as well as other states who have been closely monitoring this precedential case. The case was remanded for retrial on the malpractice issue but the decision is effective today, June 18, 2008, permitting chiropractors to adjust extraspinal areas provided they document a causal nexus to a condition of the spine.

Congratulations to the ANJC legal team of Leardi, Randolph, and Buttacci as well as Mary Ann Nobile who argued the case before the Supreme Court for the defendant chiropractors. A more detailed analysis of the case will be sent to all members in the near future.

All the best,
Sigmund Miller, DC, FICC - Executive Director
Association of New Jersey Chiropractors
Expertise. Answers. Results.
3121 Route 22 East, Suite 302, Branchburg, NJ 08876
908.722.5678 | 908.722.5677 - fax
www.anjc.info

Because service may be delivered in June, the claim for it submitted in July, and payment received in September. Thus total number of claims submitted in July is different from total number of claims submitted for services delivered in July. Similarly, total payments received in August are different from total payments received for services delivered in August. Specifically, total payments received in August is the same whether you look at it in September or in October. But total payments received for services delivered in August will continue to grow during the first few months after August, as payments continue to arrive. By blindly taking all claims submitted in July and comparing them to, say, August, your observations about claim submission dynamics will be polluted with claim submission delay, mixing claims generated in June, July, and August. Therefore, if you wish to analyze claim submission dynamics, you must order them by date of service and see how many claims were submitted for services performed in July and how many claims were submitted for services performed in August. These numbers will differ from total numbers of claims submitted in July and in August.