How to Survive a Chiropractic Audit

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Tom Necela

You’ll want to read this important article “How to Survive a Chiropractic Audit” from noted author and consultant Dr. Tom Necela… and learn about meeting any insurance challenge confidently and how to be prepared.

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A “Must Read” For Every Chiropractor Serious About Reducing Risk and Insurance Denials

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A “Must Read” For Every Chiropractor Serious About Reducing Risk and Insurance Denials Billing for Medicare or private insurance not only demands proper ICD and CPT coding, but an increasing amount of supporting documentation has become a frequent requirement. The inability to provide necessary treatment information becomes the “make-or-break” in meeting medical necessity, and can often result in costly payment …

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Steps to prevent and defend against claims of insurance fraud

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Dr. Stuart E. Hoffman, DC, FICA

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… It is when intimidation and allegations of fraud surface in a debate over provider payments that things really get ugly.

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Important coding update

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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.

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Auto Claims – Secondary Payers and Balance Billing

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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.

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CPT Coding Question, Mechanical Traction or CMT?

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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…”

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How to Split Claims

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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.

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Services at Other than Regularly Scheduled Office Hours

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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.

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Verification of Coverage Exceptions

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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?”

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Hardship Discounts – Introduction

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Keith Pendleton, JD

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.

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