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

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.

In May, the Chiropractic Office Billing Precision Index (BPI) dropped by 6.2 points below its April mark - an unprecedented change in a single month. Overall, May BPI reached 21.8, underperforming the national average of 17.7 by 4.1, and establishing the lowest BPI limit so far in 2008.

Following the pattern established in April, the May index too, replaced 30 percent of its members, adding Medicare and BCBS, both for South Carolina, and GEICO, and eliminating BCBS from three states, North Carolina, Pennsylvania, and Michigan. All three replaced participants first gained their participation in April, only to be replaced in May. The three new members in May entered the index at the bottom of the index. Note that BCBS Illinois maintained its top placement, while United Healthcare moved to the second place up from the seventh place in April, instead of BCBS Michigan, and CIGNA and Aetna returned to the third and fourth places respectively.

Billing Precision Index 21.8 - May 2008

1. Blue Cross Blue Shield Illinois 4.5 (same position, down from 1.8 in April)
2. United Healthcare 16.2 (up from 18.7)
3. CIGNA 17.6 (back to the third place in spite of losing quality down from 14.1 in April)
4. Aetna 17.9 (down from 17.5)
5. Medicare Illinois 18.4 (down from 9.7)
6. Blue Cross Blue Shield New Jersey 20.9 (down from 18)
7. Medicare New Jersey 24 (down from 21.1)
8. Medicare South Carolina 39.2 (new participant)
9. GEICO 46.1 (new participant)
10. Blue Cross Blue Shield South Carolina 67.2 (new participant)

BPI is an important billing performance characteristic because it approximates the proportion of claims that are never paid. BPI = 21.8 means that the average of ten top performing payers, used by the patients of Billing Precision providers, reached 21.8% of Accounts Receivable beyond 120 days. 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

The dramatic economic growth of India has created some negative implications for offshore Business Process Outsourcing organizations (BPO). Some of these implications can be directly attributed to the devaluation of the USD in comparison to the rupee. If this trend persists, and the USD continues to lose its value in comparison to the rupee, only the most efficient BPO’s in India will be able to continue to make a profit.

Hundreds of chiropractic offices and billing companies in the United States have outsourced their billing and transcription processing to India, taking advantage of the differences in economic development and favorable exchange rates. Outsourced billing processes typically include claims processing, coding, follow up, and data entry of patient demographics, charge and payment data. Labor arbitration between the United States and India has caused considerable heartache for numerous American transcription specialists, billers, and coders, many of whom had to find other jobs or learn new skills. But in the long run, the grand picture has paid off for both sides by creating new jobs in India, saving money in America, and creating more challenging and better paying jobs for those who stepped up to leadership and managerial roles in the new playing field.

The profits for both the outsourcing and the outsourced organizations depend directly on the exchange rate. If the exchange rate changes and the rupee appreciates against the US dollar, an Indian BPO suffers eroding profit margins. In the last six months of 2007, the rupee exchange rate dropped twelve percent from 44-45 down to around 39 against the USD. Since American doctors are paid in USD and not in rupees, the revenue of the US doctor or therapist, when translated to rupees, shrinks in step with the narrowing gap between the economic levels of these two countries and the melting exchange rate.

“For quite sometime I’ve been reviewing the bottom line margin that started to dip considerably,” writes Deepak, Head of the Medical Billing Department in one of the major Business Process Outsourcing (BPO) organizations in India. “During the past six months we adopted various methodologies to keep our cost down in all aspects (staff costs, technology, training, etc) so as not to affect the billing rates with our clients. But with rupee exchange rate dropping to around 39 against USD and with no hope of depreciating over the next few quarters, we understand that it would be very difficult to sustain our margins going forward.”

Can a chiropractic billing company with significant offshore labor components maintain its profit margins in 2008, against the background of the appreciating rupee? If not, should it reconsider the entire labor arbitration model and in-source at least some of the outsourced jobs?

If the USD continues to lose its value, in comparison to the rupee, only the most efficient BPO’s in India will be able to continue to make a profit on outsourcing. To afford the decreasing revenue per doctor, a BPO must be able to increase its volume of clients while simultaneously reducing their workload per each client through automation and, perhaps, secondary outsourcing to other countries.

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

Kirkus Review of Practicing Profitability - Billing Network Effect

Lirov offers physicians and those involved in the field of medical billing reliable advice for improving their businesses and growing revenue.

When the author looks at the landscape of the medical profession, he sees a playing field tipped to benefit the payers and hurt the providers. Large insurance companies, still reaping the benefits from years of record profitability, continue to erect and maintain huge, costly infrastructures designed to chip away at one of the last sources of new revenue—provider claims. By increasing billing costs, underpaying claims and conducting a growing number of post-claim audits, insurance companies strive to keep profits high by depressing those of individual providers.

To counteract these methods, Lirov contends that healthcare providers need to streamline their business practices. He envisions the relationship between payers and providers as adversarial, and his book is a set of strategies that will allow providers to get back into—and hopefully even win—the game. The author seeks to show providers how to enhance their billing practices with a set of strategies designed to take advantage of the “network effect,” a characteristic of systems that allows a large number of disparate providers to capitalize upon their strength in numbers.

Lirov also presents a comprehensive model for improving many elements of the provider-patient experience. He offers helpful advice on building communication with patients, improving clinical documentation (notes physicians take when dealing with patients) and facilitating the scheduling of patient visits. Lirov helpfully notes that his book is not for the billing novice, and he directs beginners to a number of other helpful primers. But for those who already have a strong handle on billing—and have a need to improve their practices to increase revenue—the book is an invaluable resource. Lirov’s writing, though sometimes weighed down by jargon, is precise and evocative, and his methods are sound and clearly explained.

A superior addition to the field of medical billing.

Author: Lirov, Yuval

Review Date: FEBRUARY 13, 2008
Publisher:Affinity Billing Inc. (189 pp.)
Price (paperback): $37.95
Publication Date: September 1, 2007
ISBN (paperback): 978-09796101-1-0

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“What is Your Billing and Office Management Plan for High Volume? Billing Precision has a unique and competent work flow technology. They increase collections, improve productivity, and reduce staff. Their programmers are open and willing to listen to suggestions.

Remember: Your ability to SAVE LIVES depends on the revenue that your practice brings in!”

-Robin Legittino, Office Manager
Planet Chiropractic, Illinois