documentation | Observations

Have you ever . . . Wished there was an easy way to make sense of the array of insurance networks out there? Should I be in? Should I opt out? Here’s a guide for you and your staff to follow to help you decide whether pursuing a specific insurance contract, and staying in, is worth your time and investment:

First, determine which companies you are in network with. Do you have a contract? What are your provider obligations? Are you getting reimbursed what the contract’s fee schedule says it will reimburse? Do you have a profile set up with the national Council for Affordable Quality Healthcare (CAQH) universal provider database and is the information current, and reviewed quarterly? There is no charge to create and maintain your profile in this credentialing database.

Second, make sure you know if you are currently enrolled in Medicare and if you are a participating or non-participating provider. Are you also currently enrolled as a provider in your state’s Medicaid program?

Third, audit your patient demographic. Run a report in your practice management software. What percentage of your reimbursement is coming from insurance? What percentage is coming directly from patients? Which payers are you mainly seeing patients from? Are you finding that patients are requesting you be in network with a certain company? Who are the main employers in your area insured with? Are you enrolled as a provider with the Veteran’s Administration in your area?

Fourth, develop a spreadsheet called “Insurance Networks” to help you and your insurance department keep the information organized and up to date.

Once you have a grasp on the above, you’re ready to determine if you need to pursue network participation with additional companies. Treating this like a sales or business venture, you’ll want to have insurance companies coming to you and requesting you be in their network. Remember, it is to their benefit and their obligation to keep their paying policyholders happy. Patients should feel free to call their insurer requesting you be on their plan. Patients have done this, and outcomes have been successful. Why? Because the worst phone call an insurance company can receive is from an upset policyholder who can’t afford to see their favorite doctor who is helping them (that’s you!) because the doctor is not on the plan.

Things to consider prior to enrolling in a plan include:

What is the reimbursement rate?
What percentage of the approved charges are taken out for contract discounts?
Is there a fee to join?
What are your provider obligations?
Do they want you to participate in their workers compensation, PI programs? (In our experience, opting in to the WC and PI products means no steerage to you, and cut reimbursements).
Are there pre-authorizations required prior to care? Is there a visit limit?
What is the initial credentialing and re-credentialing process?

Now, you are on all the plans that are making your pocketbook and your patient happy. What do you need to do to maintain your in-network status? You will need to notify a payer with updated clinic information anytime there is a change in information you submitted at enrollment. This includes phone number change, address change, adding a new provider to the office.

You will also need to make sure you are tracking re-credentialing timeframes for each insurance company. Typically, the recredentialing process for commercial payers is every three years but since your enrollments with each payer fall on different dates, your re-credentialing due dates will vary. Your Medicare re-credentialing is every five years. Re-validation with Medicaid programs is typically every three to five years, depending on your state’s standards. For example, it is every three years in WI and every five years in MI. Many of the larger commercial payers such as Blue Cross, Humana, United Healthcare/Optum Physical Health, use CAQH to approve your re-credentialing. Those who do not will send a written communication via mail or email letting you know your recredentialing is coming due and will include the applications and instructions. Make sure to track these dates in your insurance spreadsheet.

We’ve just touched the surface of network plans and credentialing. Email me for assistance with how these processes work for your practice. You may reach me at lisa@pmaworks.com
Happy Credentialing!

Lisa
“Increasing your collections through better billing and documentation”

Lisa J. Barnett

Have you ever thought you could be both a great documenter and repeatedly educate your patients on their innate intelligence . . . if you only had the time? Keep reading on how to both bulletproof your documentation for a potential audit and maintain the energy of our profession’s principles.

Let’s help build your ammunition.

First . . . did you know that the US Health and Human Services advised Medicare to target chiropractors to curb questionable and inappropriate payments, projected at $280,000,000? Seriously! And clinics are, as I write this, being audited. How do I know? Because we’re receiving phone calls and emails asking, “What do I do? I received a letter from Medicare.” As a result, I’m traveling around to help chiropractic offices prepare.

To insure yourself and what you’ve worked hard for, make sure your documentation (that is, every single note in the patient’s file/your EHR software) is citing the following information:

History Obtained at Initial Visit:
- Symptom(s) causing patient to seek care
- Family history if relevant
- Past health history (general health, prior illness, injuries, hospitalizations, surgeries, current medications)
- Mechanism of trauma
- Quality and character of symptoms/problem
- Onset, duration, intensity, frequency, location, radiation of symptoms
- Aggravating or relieving factors
- Prior interventions, treatments, medications, secondary complaints

Initial Visit or New Onset
- History (as stated above)
- Description of the present illness:
  - Mechanism of trauma (how did it happen?) For example, getting out of bed, twisting, gardening.
  - Quality and character of symptoms/problem
  - Onset, duration, intensity, frequency, location, radiation of symptoms
  - Aggravating or relieving factors,
  - Prior interventions, treatments, medications, secondary complaints
  - Symptoms causing patient to seek care. Symptom(s) must be related to the level of the subluxation documented.
- Evaluation of spine/nervous system through physical examination.
  - PART: pain and tenderness, asymmetry/misalignment, range of motion abnormality, tissue, tone changes
- Diagnosis: Primary diagnosis must be a subluxation, including the level or identified descriptive term of location, i.e., condition of the spinal joint involved, direction of position assumed by the named bone.
- Treatment plan, to include the following:
  - Recommended level of care (duration and frequency of visits), specific goals, objective measures to evaluate treatment effectiveness, date of the initial treatment.
  - Though not a documentation requirement, this is where you will educate the patient face to face, as to their subluxation and what will happen if they don’t get it corrected, as well as educate them on their innate intelligence.

Subsequent Visits:
- Review of chief complaint, changes since last visit, systems review if relevant
- Physical Exam
  - Exam – area of spine involved in diagnosis
  - Assessment of change in patient condition since last visit
  - Evaluation of treatment effectiveness.
  - Though not a documentation requirement, this is a perfect time to re-educate the patient on chiropractic principles.
  - Documentation of the presence or absence of a subluxation
  - PART: pain and tenderness, asymmetry/misalignment, range of motion abnormality, tissue, tone changes
- Documentation of treatment given on day of visit (technique(s) used and areas adjusted)
- Progress or lack thereof, related to goals and treatment plan (is the patient meeting goals?)

Let me be clear: The above documentation requirements are not PM&A’s. They are Medicare’s.

Other Tips:

Your subjective findings in initial visits/new onsets should tell a story about what happened, how it happened, and when it happened.
The Visual Analog Scale (VAS) is not sufficient documentation as your sole objective tool. Use additional tools to measure objectives findings.
See below for a typical VAS:

You should self-audit your documentation on a regular basis.

In closing, get out there, do what you do best to attract and help anyone with a spine, and follow the above documentation requirements to armor yourself in the event of an audit by Medicare and other payers. Need help staying relaxed and focused, and getting paid? Give us a call. That’s why we’re here.

Sincerely in Chiropractic,
Lisa

Lisa is now providing a no charge initial consultation regarding your Medicare documentation. You can contact at (920) 334-4561 or by email at Lisa (at) @ pmaworks.com

More information on Lisa[LINK]

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Download a customizable copy of the Checklist: [Medicare Documentation ChecklistDOC]

Print Checklist (PDF)[Medicare Documentation Checklist-PDF]

Observations

observations from our travels in the world of chiropractic

Tag Archives: documentation

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