Steps to prevent and defend against claims of insurance fraud

The world of private insurance, especially health insurance, has been the subject of one shocking exposé of exploitation and corruption after another. The abuse of the insurance industry hits providers and beneficiaries equally hard, leaving both communities feeling helpless and with a sense of little or no recourse.

The massively deep pockets of the insurance industry and the very limited government oversight that regulates their behavior means that most of the time they get their way. It is when intimidation and allegations of fraud surface in a debate over provider payments that things really get ugly.

Important coding update

As of April 1, 2010, Medicare would like providers to use a new modifier (GX) for all non-covered services. For chiropractors, this means –GX should be placed on all codes other than 98940-98942.

It is important to note that the –GX modifier means that a valid ABN is on file for the non-covered services for which the –GX is used.

Auto Claims - Secondary Payers and Balance Billing

Problem
There is confusion on when to bill group health plans as the secondary payer, with discounts, when the auto Med-Pay is used up.

Findings
Supplemental insurance plans with contractual discounts in the patients' group health plan are typically not affected by the type of primary carrier. The fact that it is an auto claim is irrelevant. Insurance contracts usually have "coordination of benefits" clauses to address such secondary matters.

Mechanical Traction or CMT?

Problem
Some payers are denying Mechanical Traction (97012) on the same date of service as the Chiropractic Manipulative Treatment (CMT 98940-98942).

Findings
Here is the rationale of one payer: "...both mechanical traction and spinal manipulation on the same date of service as the procedures, for all intents and purposes, are redundant..."

Medicare Billing For Non-Covered Services

Problem
Can providers collect their regular full fee from Medicare patients when the service is denied or not covered (such as Maintenance care) by Medicare? Many offices and billers are confused and want true facts to avoid any improper billing.

How to Split Claims

Historically, splitting the claim was viewed by some as being not appropriate and had the appearance of fraud. Interestingly, with our new age of processing by computers, this old perception is now dead. Computers can now compare all services instantly, no matter how many claim forms they may be on.

Services at Other than Regularly Scheduled Office Hours

Problem
Leaving money on the table for services that are performed after hours and at other special times.

From a CPT coding perspective there are special adjunctive codes that are used in addition to the basic service(s). This code series ranges from 99000 to 99099.

Within this series are important codes that deal with special service situations.

Verification of Coverage Exceptions

Problem
Knowing how to cope with invalid coverage information from insurance companies.

Here is a typical example from a client:
"On March 26, we were told that the patient had coverage effective in December and that it was still active. We submitted our claim and it was paid. Now, all of sudden, they are saying the policy was canceled in February before our phone call, and they are asking for their money back. We had no knowledge of this cancellation and trusted them. We just followed normal routine procedures. I have appealed and my appeal was denied. What is my next step?"

Hardship Discounts - Introduction

What Are They and How to Safely Create One Based on the Patients' Poverty level?

A major shift is occurring in the health care industry. Deductibles are going up. Insurance is paying for less and less. The number of uninsured Americans is on the rise. The shift, referred to by some as the "rise of the self-paying patient," is creating nothing shy of a crisis for many healtlfcare providers.

One of the issues, for example, relates to discounts, i.e. discounting the patient-portion-due. A lot of providers are being tempted to discount, or even waive entirely, the patient-portion-due as a way of making care more affordable for their patients.

Worried About Audits? Be Preventive, Not Reactive

Executive Director of the Ohio State Chiropractic Association Bharon Hoag offers insight on how chiropractors can effectively prepare for increased audit volume proposed in the Office of Inspector General's (OIG) 2008 work plan. The 2008 work plan includes a 40 percent increase in chiropractic audits from its 2007 plan. Who can know who's next – or when?

The key to avoiding audits in the first place is preparation – making sure you can support the claims you submit. That entails…

Don't Cheat Yourself on Therapeutic Procedures a.k.a. Don't Cheat Yourself!

Numbers — specifically, numbers used in coding — tell a story. And good “storytellers” — coders — get paid properly. Those who do not know how to tell their stories correctly do not get paid fully and fairly.

The gray areas have to do with therapeutic procedures — what doctors and therapists do with their hands — and the problem often begins with the first patient visit.