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Questions & Answers

 

Can chiropractors claim “write-off’s” on their taxes?

No. If the money never came into the clinic, it cannot be claimed on taxes.

I am looking to rent a room in my office to a massage therapist. Can we do an hourly rate for the room as an independent contractor?

It is recommended that you consult your attorney before entering into any sort of contract. To be considered in the contract are Stark laws, anti-kickback, fee splitting and taxes.

Are insurance companies or adjusters obligated to return calls from a provider’s office?

No. They are under no contractual obligation to the provider.

Can providers offer prepayment plans to patients?

It is important for you to consult your attorney and/or individual state laws restricting prepayment plans prior to engaging in this practice. If your state does allow for prepayment, be sure the funds are properly deposited into a separate escrow account and all payments made to the clinic from that account are properly documented. It is also recommended that you have a reimbursement plan in place that the patient agrees to prior to care, should they elect to discontinue treatment at any point.

How long do I need to keep my patient sign-in sheets and treatment notes?

As long as the longest record requirement by the various networks and the med mal statute, plus 1 year. General rule of thumb is ten years.

Does a Medicare patient with a true secondary insurance need to sign an ABN form?

Yes. I recommend having one master ABN with all potential non-covered services.

Are x-rays required to document a diagnosis for Medicare patients?

Yes, unless a PART exam is used to document the subluxation.

Can a provider discount a non-covered service such as decompression to a Medicare patient, since Medicare won’t be paying for the treatment?

No. Federal Inducement Law prohibits a provider from offering anything of value to a patient with federally funded insurance.

If an office performs 8 minutes of a PT code with no other PT codes, there is no issue in billing for a full unit, is there? Someone told me that unless a full 15 min. is done first, that billing the 8-14 minutes is not acceptable.

There is no issue in billing for a full unit if an office performs 8 minutes of a PT code with no other PT codes.

Can you extend a discount or reduce the bill for a Medicare patient whose entire claim gets denied by Medicare (citing no coverage exists) and who selects 1 on the ABN?

Financial hardship is the only legitimate reason for extending a discount to a Medicare patient.

My staff asked me a good question in regards to billing today. If one submits a bill with a diagnosis and that bill comes back with a “pre-existing” clause and is denied, can one re-submit but with new diagnosis codes as long as they apply?

Yes, so long as the resubmission is truthful as noted below:

For example patient has lower back pain and sciatica (739.3 and 724.3 were ddx) but also has radicular symptoms in the upper extremity but were not listed on ddx (you can only “see” 4 of them on HCVA or e-bill) but were listed amongst the 9 ddx codes in our practice management software and clinical documentation exists on the intake form as well as the exam form. Can we re-submit using other codes that identify that as long as treatment consisted of that area (3-4 regions adjusted, tpt/stm, ultrasound to this “new” area documented on SOAP notes and therapy card).

If a person is scheduled for a group therapy procedure (97150) and someone in the group doesn’t show up, it could cause the ratio of patients to providers to be 1:1. In that case, is it acceptable to keep the reported code at a 97150? Specifically, if it were a cash patient, would they be required to pay the 97110/97112 if they ended up in the 1:1 ratio even if they were scheduled to work in a group (97150) setting?

You always use the code that most properly identifies the service performed. So even if you intended a group service, but a one on one service occurred. You must use the one on one code. Offering a deal legally would depend on the applicable jurisdictions laws.

Insurance Questions

I’ve received a lot of insurance denials recently and am considering moving to a cash practice. Is this recommended?

First, it’s important to understand that there is no such thing as a 100% cash-only practice unless you decline to treat any Medicare patients, including older or disabled family members. Moving to a cash practice doesn’t suit all providers and the decision to do so comes down to a couple of main factors:

1. What is you risk tolerance? Some studies have shown that between 60-70% of patients would prefer to pay for visits with their insurance. Are you able to take a chance that your patient base will stay or that you will be able to attract a new patient base through offering lower cash prices?

2. Are you able to withstand the transition? Cash practice doctors must do a better than average job in educating their patients about the benefits of wellness visits.

3. What is your current insurance environment? In other words, do you reside in an area where most patients have and use health insurance and are collection rates fairly regular? If so, perhaps cash practice wouldn’t be the most financially savvy move to make.

A major benefit to cash practice is generally lower overhead costs for you and not dealing with insurance denials, co-pays, resubmissions, etc. Regardless of what direction you are leaning, it is always recommended that you seek the guidance of a skilled attorney or financial advisor who can look at your clinic’s unique financial position and construct a transition plan that best paves the way for long-term success.

How many adjustments is a Medicare patient required to have a re-exam?

There is no set number. I good rule of thumb is 12 to 18 visits. 18 works nice since that is an average for moving a patient from medically necessary care to wellness care.

What are the main things we need to consider when moving to electronic health records (EHr) systems?

1. Compliance. Be sure the system meets standard HIPAA requirements to preserve your patients’ privacy as well as to comply with state and federal guidelines.

2. Meaningful usage.

3. Useful practice management aspects, including patient scheduling.

4. Seamless integration with current work flows

5. Compatibility of the system with the needs of the practice.

Are chiropractors allowed to practice in hospitals?

Be sure to consult with the hospital administration prior to conducting any adjustments on patients or the new babies of current patients, regardless of whether or not the patient offers expressed consent. It is important that you understand and respect the hospitals policies regarding treating patients while under the hospital’s immediate care. Many hospitals are allowing chiropractors into their facilities but most do require a certain application process to be completed in advance.

Can I market my business by using patient testimonials on social networking sites like Facebook or at seminars and conventions to educate the public?

Yes, but be sure your patients sign a specific written consent detailing how their testimonials will be used. Even though you are likely very passionate about the patient’s progress, be sure you are not disclosing the nature of their personal medical history or conditions without their written and expressed consent.

Are X-rays required to document a diagnosis for Medicare patients?

The answer is now. In order to treat a Medicare patient, you do have to diagnose the subluxation. You used to have to do an x-ray in order to do that. Now you can do either an x-ray conduct what is called a P.A.R.T. exam. That exam will demonstrate the existence of a subluxation without an x-ray. Be very careful when you do the part exam because they try to make P.A.R.T. exams seem simple, but they aren’t. If you miss one section of the part of the exam, you’re going to have some trouble proving medical necessity of the chiropractic adjustment for the subluxation and Medicare, so be careful of that. A lot of good electronic health records systems will not allow you to save the P.A.R.T. exam form unless you’ve complete all the required elements of the form. I recommend that you use a good electronic health records system that does things like that and stops you from saving a record of an examination that’s not complete

What should Chiropractors claim on their taxes as income when they barter their services for other value with patients?

Chiropractors should claim on their taxes the value of what they bartered for. So, if they were given a chicken and the chicken was $10, they should claim $10 of income with the IRS.

Can Chiropractors claim write-offs on their taxes?

The answer is no. Obviously you should check with your CPA on this, but if you never received the money to begin with, you can’t claim it as a tax deduction later on.

What should you do when you switch from the deal to regular charged services?

Often times, a clinic will offer a deal like a pre-exam or pre-x-rays if needed to a patient as a patient promotional, to get new patients into the clinic. One really wise thing to do though is when you get to the end of the free service, you should have a disclaimer signed by the patient stating that they understand that the free service has ended and all services from that point forward will be at your regular fees. Then the patient doesn’t get surprised. I’ve seen some board complaints result when the patient is surprised to get the bill after the deal is done. They didn’t really understand what the charge or the deal was and got confused about it. So a little written disclaimer at that point in time when the deal ends and the new thing starts is a wise thing to do.

If one submits a bill with a diagnosis and that bill comes back with a pre-existing clause and is denied, can one re-submit but with new diagnosis codes as long as they apply?

The answer is yes. Often times you’re diagnosing several conditions, usually more than four conditions. The CMS 1500 claim form only allows you four spots to put diagnoses on that claim form. Many times you have many more diagnoses that you could put on the form but due to limited space, you just put the four in. It’s not a problem if you think a different diagnosis would apply and would actually overcome the denial, to send in a replacement claim or substitute claim to see if you can get that service paid using a different diagnosis code. The important thing to keep in mind is, is it truthful? Does that diagnosis code apply to the services you’ve provided? And if the answer is yes, then go ahead and change the diagnosis code and resubmit.

Can providers offer pre-payment plans to patients?

Generally speaking, yes. A lot of states have specific rules on how you do prepayment plans. Some states say that you can’t do prepayment plans, like in South Dakota. You can’t do a prepayment plan. You can designate how many visits you think the patient might need, but you can’t collect before had for those visits. You have to wait until the end of the month or end of the plan to collect. In other states like Minnesota and Florida, and this is growing right now in Chiropractic, more and more states are requiring a specific set of things you must comply with in order to do prepayment plans. And just by principle, this is what those things are:

1. You need to treat the money that you’ve received from the patient on a prepay plan as the patient’s money until you actually render the service to the patient.

2. The money should be set aside. You can pool all patient prepay plans into one trust account, but it should not be used or taped into and transferred into your operating account until you’ve actually given the services to the patient.

There are a couple of really good reasons for this:

1. Death. What would happen if you died suddenly and nobody was there to take over your clinic? The patients would be entitled to that money back and if there is no money in a trust account to give back to them, then there is going to be a lot of really unhappy people. You want to make sure you take care of those patients and make sure they have money available.

2. A Move. If a patient would come back to you and say, “Listen, I’m moving out-of-state and I’m not going to be able to come in for all of those visits. How much am I owed?” It’s real important that you be able to determine how much is owed to the patient and give them a reimbursement right away. If you don’t have money set aside in an account to do that, that could cause some problems for the patient in getting their money right when they request it.

Be very carful on how you do deals. When you add a percentage deal onto a prepayment plan, it’s very, very hard to calculate exactly what services are going to cost. And remember, when you are doing a prepayment plan, you are just making a recommendation for future care. Rarely does a patient get exactly what you are recommending. The patient either gets more or less and unless you have a per-service fee determined down to the penny, you’re going to have a really hard time tracking that in your billing department. So, do your billing department a favor: Don’t do percentage deals on top of prepayment plans. Get, down to the penny, what services are going to be charged at. Stick with that, track what services they actually had, whether its to the plan or a little bit divergent from the plan and make sure that you’ve got a good contract in place that tells the patient and your clinic what’s going to happen if they want their money back quickly or before they end the plan or what’s going to happen if they get services not listed in the prepayment plan.

Can a clinic use patient testimonials in their office?

The answer to that is that it depends on the state laws and board rules in that state. It’s very easy to find out what those rules are. Just go on line, go to your state board, and look up the rules and laws. You can even just search on advertising restrictions or just advertising and you’ll find the rules right there. Generally speaking, you can include patient testimonials as long as they are truthful and not fantastical, like “The doctor adjusted me and I went to the moon and back!” That’s not possible; it didn’t happen. So as long as it’s not fantastical, as long as it’s truthful, you can generally do them. Just check with your state laws and rules. Some of the different states will have rules like the testimonials have to be in writing, they have to be signed by the patient, a copy kept in their patient file, or even pre-approved by the state board. So, check your rules and generally speaking, you’re able to do that.

It’s also wise when you have a patient testimonial, of course you’ve got to apply with HIPAA which means that they give you permission to use that testimonial and while you’re getting that permission under HIPAA, you can make sure that they sign off on any rights to that information or any sort of compensation for giving that patient testimonial or recommendation.

Can you extend a discount or reduce a bill for a Medicare patient whose entire claim gets denied by Medicare (citing no coverage) and who selects Option #1 on the ABN?

The best rule of thumb with Medicare is to never give a Medicare patient a deal or a discount. There’s a law called the Inducement Law that you might come into conflict with if you give discounts or deals to anybody covered under Medicare. There is one general exception and that is if you can prove that your patient has financial hardship. Many large clinics, hospitals and chiropractic clinics do this by establishing the household income for that patient. Typically they’ll state that the patient will qualify for a hardship discount if the household income is two or three times greater than the poverty index.

The general rule is no. Don’t give a deal to any of your Medicare patients.

Does a Medicare patient with a true secondary insurance need to sign an ABN form?

I recommend that every one of your Medicare patients sign an ABN form. You can do this by having all new Medicare patients sign an ABN form when they come into the clinic for the first time, or if they are coming to the clinic later on, make sure they sign the ABN form at least once a year. Another good time to have them sign the ABN form is if they move from medically necessary care to wellness care and you want to inform the patient that their chiropractic adjustments are no longer a covered service under Medicare because they’re now wellness visits. So that is also another good time to do it but generally speaking yes, every single one of your Medicare patients should have an ABN on file. An ABN designates and Advanced Beneficiary Notice. If later on you forget to do this for a while, generally speaking, its not going to get you into deep trouble with the federal authorities because if you end up audited and don’t have an ABN form, often times they just say that because you didn’t have an ABN form and if they’re asking for money back or they say that they overpaid you or something like that, the lack of having an ABN form only makes it difficult or impossible for you to make the patient pay for that care that Medicare is now denying. So, that is the only big reason to do it. From a compliance standpoint, you’re not going to get into too much trouble by not having an ABN. However, I do recommend that you do it anyway just as a course of action. It’s a good thing to let your patients know what is covered and what is not going to be covered when they come in for their chiropractic treatment.

If a patient has a Medicare primary and Medicaid secondary, is the office required to bill medical or non-covered services, or would the ABN allow the office to bill the service as cash?

Whenever you’re dealing with the federal and state government, you’re going to have a whole bunch of laws and rules you’re going to have to follow. Depending on the state that you’re in, just follow the rules for your state’s Medicare. The general answer is no. You can’t bill them separately. You’re going to have to comply with the rules of Medicaid and most of the time, they’ll make you complete a claim to Medicaid and accept whatever they pay, plus if there is any deductibles or co-insurances that apply. Generally speaking, the answer is no. You’ve got to follow the rules as if you’re an in-network provider with the fee schedule.

How long do I need to keep my patients sign in sheets and treatment notes?

Generally speaking, across the country, keep all of your patient files and sign in sheets for the length of time for your malpractice statute of limitations in your state. For instance, in Minnesota, it’s six years. So, the minimum amount of time is six years, plus one year, so a total of seven years for a state like Minnesota. When you’re dealing with the federal government, often times they’re rule is ten years so you’re never going to go wrong in keeping things up to ten years. Now, the beauty of an electronic health records system is that you don’t have to worry about that. You don’t have to have these basements filled with papers that get flooded out, misfiled, or you can’t find them. If you use an electronic health records system, everything is stored offsite and backed up. You don’t have any problem losing it and you don’t need to get rid of any of it at all. It would be nice to be able to go back twenty years and have a record. I wouldn’t worry too much about it if you’re on an electronic health records system because you can keep those records forever.

Are insurance companies or adjustors obligated to return calls from chiropractic offices?

No. They aren’t obligated. They often times won’t return phone calls and they’ll often lose your claim filing and treatment record. When that happens, don’t be surprised. Just professionally call again and resend them the requested information. They are often very busy and have no obligation to you. They do have an obligation to their insured, but not to you.

I’m looking to rent a room in my office to a massage therapist. Can we do an hourly rate for the room as an independent contractor?

This is a very complex issue. Generally speaking, it’s hard for you to really prove that an independent contractor is truly independent because most of the time in the clinic, you’re going to want to exert some control over them. If the IRS ever sees that you exert control over that independent contractor, and that independent contractor fails to pay their taxes, you’re going to find the IRS coming after you for that independent contractor’s taxes, penalties and interest. You’ve got to be very careful when you do independent contractor agreements. Is it possible to do an independent contractor agreement with a massage therapist and do it legally? Yes. You have to make sure you don’t exert any control over them and you have to make sure you don’t run afoul of the Stark Law, fee splitting laws and the anti-kickback laws. That’s very hard to do under most contracts. One way you can do it is by doing a rental agreement for fair market value that exceeds one year. In other words, what you charge for rent cannot be associated in any way with how many massage referrals they are getting from you or how much volume they do. It has to be for fair market value and you should get the opinion of a realtor before you enter into those agreements.

You can probably tell that I’m not too crazy about independent contractor agreements even though they are rampant in the chiropractic profession. I’ve been down too many roads having to do with defending chiropractors for those agreements when there really is a much simpler solution, which is to just hire them. You can do all sorts of deals and percentages if they’re part of your group practice. You don’t run afoul of federal law, you won’t have trouble with your taxes, and it’s just a lot simpler. That’s the way I generally recommend that clinics do this.

Can a provider discount a non-covered service such as decompression to Medicare patients since Medicare won’t be paying for the treatment?

The answer is no. If you give anything of value in excess of $10/time or $50/year, you’re subject to a potential violation of what’s called the Inducement Law, which carries a $10,000 penalty from the federal government for each violation. You have to be very careful in giving any deals or discounts to your Medicare patients. There is the exception of hardship, which you can look at with other questions on this website, but the important thing is to avoid violating the Inducement Law. When it comes to non-covered services, find the appropriate service and its appropriate fee in your clinic. Don’t change it to a lesser fee. Bill the patient for that amount and you can avoid violating the Inducement Law.

If you’ve scheduled a group therapy session, but some patients do not show up, causing the ratio of patients to providers to be one to one, is it still acceptable to code the session as group therapy?

A lot of these coding questions become quite complex with a lot of different “what if” scenarios. Here’s the clear and clean guidance that you should follow. Always code with the code that most properly identifies the services performed. If you are planning a group therapy with more than one patient, but you ended up treating just one patient, then using the group code for that single patient would not be appropriate. You would need to use the other timed code for that service. Pretty simple and straight forward. Just take each separate incident and always apply that rule. Always code with the code that most properly identifies the services performed and you’ll always be in great shape. I often times get the question, “Can you down code?” The answer is yes, you can down code. You should never up code because it looks like you’re trying to get paid more. Down code simply means that you’re using a code that describes something you would normally do less of. For instance, if you did a Level Two examination but you down coded and only charged a Level One examination, you’re ok. It’s ok to down code, even though you’re not using the code that most properly identifies the service. Why? Because there is no profit motive. You don’t have any problems using a code that pays you less but you’ll always have a problem using a code that pays you more, which is up coding, especially if that up code does not properly identify the services you performed on that patient.

When you run an ad in the newspaper are you allowed to advertise wich insurances you accept?

Typically the answer to that is no. A lot of the networks provide in their contracts that you cannot list them as a company that you do business with, unless they’ve got it clearly stated in their contract that you can that. So, generally speaking, the answer is no but look at the network contract and that would give you the quick answer.

Can you advertise free exams or discounted services to new patients?

The answer to that depends of course on the state that you’re in, with one caveat. If you can offer any free exams or other free services in your state, by the rules and regulations of your state board, always be sure to include a Medicare disclaimer that says something to the effect of, “Unfortunately we cannot offer this deal to Medicare or Medicaid patients due to federal law”, or something like that. If you did provide those free services to a Medicare or Medicaid patient, you would violate the Inducement Law. So, check with your state. If you want to be very, very conservative and know that you’re not ever going to get into trouble, just don’t ever do any deals. That’s one way to do it. If you’re really intentional and think through your services and the fees that you charge, you can get pretty close to giving some fantastic deals, even though you’re giving just you’re regular rate. For example, you could do a level one examination for $10. Maybe your level three examination is $150. You aren’t quite giving away the examination, but because of the way you’ve designed your fee schedule, you can really meet the needs of those patients, assuming that all they need is a level one exam, you can meet their physical and financial needs at the same time.

If an office performs 8 minutes of a PT code and no other PT codes, there is no issue of billing for a full unit, is there?

As long as you did just one therapy code and you did that therapy for eight minutes or more, you can bill it at the full 15-minute rate.

What is your advice on advertising?

Advertising is a pretty hot topic for chiropractors across the country, so I’m often asked “How can I advertise affectively, but also be compliant?” My answer back to them is “What state are you and are you trying to advertise to people with Medicare? What business or clinic model do you have?”

One fascinating thing about advertising nationwide is, when I first got into it I thought, why are all of these rules so restrictive for chiropractors? At first I thought, it must be the attorneys that are trying to jam chiropractors up or maybe it’s the medical profession that’s trying to take market share from chiropractors, but when you dig down deep and try to figure this out, what you’ll discover is that often times these really cumbersome rules that detract from effective marketing came from a well-known chiropractor in your state. At some point in time, they were having a very profitable clinic and then a young upstart comes into their town, sets up a chiropractic clinic and starts taking patients away from them so their thinking, “Well they must be cheating. It can’t possibly be that the patients might want to treat with them rather than me.” So then they talk to the legislature or they go to the board and they come up with these rules that jam us all up. Then, years later, we are all struggling, trying to operate fairly and compliantly within those rules.

Help! I got my first board complaint. What do I do?

So, you got your first board complaint. Don’t worry; you’re going to be ok. The sky is not going to fall, you’re going to be fine, and your patients are going to keep coming in. Everything is going to be alright. You’ve got to just take a deep breath, get a good healthcare attorney to defend you, and you should be in good shape.

Rarely do board complaints result in you losing your license. So don’t automatically think, “Oh, I’m just going to lose my license”. And here’s another tip for you: Plan on getting a board complaint every year. If you do that, it makes you stronger. It makes you do your treatment notes better. It makes you do your coding and claims better. It just makes you more professional and protected in the event that you do have a board complaint.

Also, you get that board complaint, it comes, and you go “I’m going to get a good healthcare attorney to help me out with this.” You send it over to them. Then you just compartmentalize it in your head and you get right back in there with your patients and you take really good care of them because this is what it’s all about. Your mission is to save their lives, to help get them well, to get them out of pain. You’ve got to keep your eyes on those patients. Let the attorneys deal with that board complaint and you’re going to be in good shape.

What are the advantages of Cloud Service?

What are the advantages of Cloud Computing? And is it safe and secure? Well, any cloud computing company that does online software, billing service, clinic practice management software has to be HIPAA complaint, so you don’t have to worry about that. Your information is safe and secure. And in fact there are federal laws about your information even if you should decide to leave that company, you have rights to that information and there are easy ways to get that. The big advantage of cloud computing is that you can combine not only software with actual service coming from experts in billing, coding, compliance, legal defense, and things like that. So it’s really pretty cool when you open up your office to the entire world, you can virtually get really highly qualified experts in many fields to come in and help you and be your wingman in your clinic, to make sure your clinic is taking really good care of the patients and maximizing your profits.