Does United Healthcare Discriminate Against Chiropractors?

Who's "at it" again?

In an article titled, "United Healthcare: Here They Go Again" (Dynamic Chiropractic - April 9, 2007, Vol. 25, Issue 08), James D. Edwards, D.C., currently serving as an "Alternate Delegate" ("Tx-East") in the American Chiropractic Association, stated:


The American Chiropractic Association (ACA) has received reports that United Healthcare has implemented a new policy in several states to only reimburse physical medicine and rehabilitation (PM&R) services when performed by a licensed provider.


The new policy states, "PM&R services rendered by non-licensed individuals are not eligible for reimbursement, regardless of whether they are supervised by, or billed by a physician or other licensed therapy provider." This change is effective as of Jan. 1, 2007 for newly contracted providers and April 1, 2007 for currently contracted providers.


So, what exactly does this new policy mean for doctors of chiropractic? In Texas, where United Healthcare is applying the policy, it means a doctor of chiropractic will not be reimbursed for physical medicine or rehabilitative treatments unless those services are actually performed by the doctor or by a person licensed by the state to do so . . ..

Does Dr. Edwards actually identify a disparate situation for chiropractors vis-à-vis other licensed healthcare providers (e.g., MD, DO, PT, OT)? There is no evidence of such a disparity, at least per the reference cited.

However, there can be little doubt that chiropractors perform such services at a much higher rate than other physician-providers on a per-capita basis.


Does Dr. Edwards identify a new policy in reimbursement-standards within the Insurance industry? Dr. Edwards states, "[T]his change will greatly impact patients and providers across the country . . .." He goes on to state:




[I]f you are a non-licensed chiropractic assistant who applies a heat pack or assists a patient with rehab, you will not be reimbursed! Think that might change the way you practice? (ibid.)



I am unaware of any insurance carrier that will "reimburse" a "non-licensed chiropractic assistant." Furthermore, I'm not certain that the position articulated correctly posits United Healthcare's reimbursement standard(s).


It is significant to note that the CPT Guides are unequivocal in distinguishing between supervised and attended modalities. Additionally, CPT distinguishes between "modalities" and "therapies" in the following manner:



Modalities are defined as "Any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy." They may be attended or non-attended.


The definition of modalities was added to CPT 1995 to indicate the different types of service included in this section.


To clarify the work performed by the provider, the section is divided into two parts; Supervised and Constant Attendance.


• Supervised modalities are defined as the application of a modality that does not require direct (one on one) patient contact by the provider.
• Constant Attendance is defined as the application of a modality that requires direct (one on one) patient contact by the provider.


Therapeutic Procedures are defined as "A manner of affecting change through the application of clinical skills and/or services that attempt to improve function." These require direct patient contact.


The definition of therapeutic procedures was added to CPT 1995 to clarify the differences between therapeutic procedures, modalities, and tests and measurements. These procedures require direct one on one patient contact by a physician or therapist. [At times, the foregoing terms are collectively referred to as "Provider" by CPT - both meaning someone licensed by the State to perform health care services.]


Therapies is a kind of general term used by many people to describe all physical medicine procedures -- modalities, therapeutic procedures, acupuncture, and sometimes, even CMT.


Most insurance companies will refer to the CPT terms described above. (http://www.chiro.org/ChiroAssistant/Articles/Modalities_vs_Therapies.shtml)



It would appear that United Healthcare is merely applying the applicable CPT codes in the manner the AMA CPT Guides intended. It is not clear why Dr. Edwards perceives that the application of the codes in the manner intended would justify issuing this alarming statement:



The NCLAF ["National Chiropractic Legal Action Fund"] has repeatedly told the chiropractic profession that the concern is not if our adversaries will attack us again, but when they will attack us. And sure enough, here they go again. Fortunately, the NCLAF shifted its focus to building a legal "war chest" for just this type of attack, and has reserves ready to commit to the fight. The ACA and the NCLAF continue to protect and defend your practice, your patients and your profession.



I know of few chiropractors who would not be concerned regarding the current insurance-reimbursement landscape, particularly as it pertains to Chiropractic. However, is the fact that chiropractors are treated in the same manner as other similarly-situated providers justification to break open the "war chest" and rally the troops?


The Chiropractic profession has much to offer the Healthcare community. As we, as a profession, consider what it is that we have to offer, we should proceed judiciously in that arena in which we have clamored for parity for decades, threatening to play the "victim" card when we finally receive the parity for which the battle was fought.


It appears as though one may justifiably ask, "Is it United Healthcare or the Chiropractic profession that is 'at it' again?"



About the Authors:

Dr. Tom Rhudy is licensed as both an Attorney and Doctor of Chiropractic in the states of Texas and Missouri. Daniel J. Osborne, M.S., is a renowned expert on health care fraud issues and recognized authority on health care compliance.

For the past 20+ years the authors have devoted most of their efforts toward educating and assisting providers in the development of healthcare treatment and compliance programs and prevention of healthcare fraud and abuse, making every effort to improve the quality of care and representation provided to patients.

For more information about creating an effective Healthcare Compliance program, designed to prevent healthcare fraud and reduce healthcare costs, you may go here: http://www.HealthCareComplianceTraining.net

Do Healthcare Compliance Programs Prevent Healthcare Fraud and Reduce Healthcare Costs? Part III

Okay, now that you've developed your Healthcare Compliance policies and procedures, what's the next step? Great question!

After all, if you have policies and procedures, but no implementation, is the program effective? How would such an inert Healthcare Compliance program prevent healthcare fraud and reduce healthcare costs? You're right, it wouldn't.

I have provided a few recommendations regarding ways in which to conduct effective training for your Healthcare Compliance program. (I've also shared a few lessons learned along the way.)

Training Sessions: Once the foregoing are completed, it will be necessary to set a time and place for the training session(s). It is important to conduct the training in a manner most likely to capture the largest number of employees/agents for which the training is intended. Any employees/agents who do not attend the plenary training session should be required to either attend a make-up training session or provide evidence of having obtained the information contained in the training session.

Training Location: Ensure that the location of the training session is conducive to such training, and interruptions will be minimized. During one of our first compliance training sessions, the room in which we conducted the training was so hot that by the time we were finished, participants were practically stripped down to their underwear.

Sound System: Ensure that you have an adequate sound-system. Too often, speakers conclude that they do not need a sound-system. Remember, sound-systems are for the listeners, not the speakers. It is also important to avoid having individuals attending the training session sit in areas that are “dead-spots,” acoustically-speaking.

Sign-In Sheets: Provide a sign-in sheet, identifying the date on which the training session is conducted, the employee’s/agent’s printed name, and the employee’s/agent’s signature.

Pre-Test: Provide Pre-Test 1A to all employees/agents to determine the knowledge- base of the participants prior to the training.

Videotaping Training Session: Training sessions should be memorialized, preferably via video. It is recommended that the taping, irrespective of the medium, be performed by a professional. If you do not know where to obtain such a professional, it is recommended that you contact a court-reporting service for recommendations. It is difficult to convince investigators that you take your compliance training seriously when an inattentive videographer allows the camera to focus on the back of someone’s head for ten minutes and the audio includes private discussions amongst audience members.

Q&A: Conduct a Q&A session following the training. Remember the following: (a) have speakers repeat questions asked; (b) ask participants to rephrase ambiguous questions; and (c) refrain from addressing questions that are not relevant to the training session, stating that you will be happy to discuss the issue with the questioner at a convenient time following the training session.

Post-Test: Provide Post-Test 1A to all employees/agents to determine the knowledge-base of participants following the training session. This will be a good metric to assess the effectiveness of the training session.

I hope that this is beneficial. Remember, if you have additional questions, please feel free to contact me.

You may obtain additional information regarding ways in which to design an effective Healthcare Compliance program, a program that has demonstrated its effectiveness in preventing healthcare fraud and reducing healthcare costs, by going here:
http://www.HealthCareComplianceTraining.net

Do effective Healthcare Compliance Programs prevent healthcare fraud and reduce healthcare costs? Part II

Delegation of Duties: It will be necessary to appoint a Compliance Officer who is qualified to oversee a healthcare compliance program. If you do not have an employee in your organization with such training, we have provided, and make available additional, resources that will prepare the appointed individual to assume such a role.


1. Compliance Officer: The individual appointed must be someone who refuses to compromise the quality and integrity of the compliance program. Policies pertaining to billing, coding, documentation, etc. should be viewed as mandatory, not optional!
2. Compliance Committee: Once your Compliance Officer is appointed, it will be necessary to determine what departments within your practice should be represented on a Compliance Committee to which the Compliance Officer will report. Frequently, providers mistakenly conclude that the practice consists of only one department. Rarely would this be the case.

Most practices will have, if nothing else, the following: (1) record keeping; (2) billing; (3) collections; and (4) production. Although one individual may wear hats for each department, it is best to consider these departments as discrete entities. This permits more effective management and analysis of your overall practice.

Compliance Manual: The Compliance Manual we have prepared addresses areas of exposure to which attention must be directed to attenuate (i.e., lessen) the exposure arising in each area. This is one of the most critical areas of any compliance program, and should not be given short-shrift.

Employee Manual: We have also provided an Employee Manual in which examples of employees’ duties and responsibilities are provided. It is recommended that the manual be tailored to the individual practice. While the duties and responsibilities included pertain to the principal areas of most healthcare practices, undoubtedly your practice has one or more unique areas that would benefit from slight modification of this manual.

Vendor/Agent Contracts: We have also included sample contracts to be used when working with vendors, independent agents, and licensed providers who are not employees of your organization.

Hotline: We have provided Hotline protocol, intended to provide a viable reporting mechanism for concerns/complaints concerning the organization’s practices. This protocol is effective in providing a reporting mechanism for concerns/complaints arising either internally (i.e., employees) or externally (e.g., patients, insurance adjusters et al.).

Education: The policies/procedures contained in the manual serve as an excellent educational tool for all employees, agents et al. However, to be effective, as is true for all education, it is necessary for those policies and procedures to animate those with whom they are shared. Merely having a dormant document in which such policies/ procedures are contained will not accomplish your intended goal of developing a vibrant bona fide healthcare compliance program.

Disciplinary Procedures: We have provided a guide to Disciplinary Procedures, applicable to both licensed and unlicensed employees. It is important to bifurcate these disciplinary procedures to ensure licensed providers that they are the individuals to whom boards of examiners will look for accountability, to whom law enforcement will look as the instigator of abusive and unnecessary procedures, and to whom governmental agencies will address inquiries into questionable/unusual practices. Unlicensed individuals must realize that their activities may also result in the accrual of personal criminal liability. Neither licensed nor unlicensed individuals are immune from prosecution. I was involved in one investigation in which a provider whose name was affixed to billing statements had been dead for more than six months, and the office manager’s sentence was actually longer than the doctors’.


Exit Interview: We have provided an Exit Interview form, as well as procedures to follow when employees sever their employment relationship, whether it be voluntary or otherwise. Failure to perform this procedure may result in many unnecessary claims (e.g., wrongful termination, “whistle-blower” actions, etc.) and prove extremely costly.

About the Author:

Dr. Tom Rhudy is licensed as both an Attorney and Doctor of Chiropractic in the states of Texas and Missouri. While serving as both an Attorney and Doctor of Chiropractic, he has worked closely with law enforcement, insurance carriers, administrative agencies, the FBI, US Attorney's Office, the US Postal Inspector's Office, and healthcare providers in the prevention, investigation, and prosecution of healthcare fraud.

For the past 20+ years he has devoted most of his efforts toward educating and assisting providers in the development of healthcare treatment and compliance programs and prevention of healthcare fraud and abuse, making every effort to improve the quality of care and representation provided to patients.

To obtain assistance in developing an efective healthcare compliance program, you may check us out here:
http://www.HealthCareComplianceTraining.net

Can an Effective Healthcare Compliance Program Prevent Healthcare Fraud and Reduce Healthcare Costs?

If you realize that you need a healthcare compliance program, but feel apprehensive about what seems to be such a daunting task, this Guide will assist you in gaining the confidence that you need to proceed step-by-step in creating a healthcare compliance program that will make you proud to be a healthcare provider once again. This Guide will show you the most important elements to consider in the development of a compliance program, irrespective of the size of your practice.

It is dangerous to assume that because your practice is small (e.g., 1 doctor and 1-2
staff members), that you do not need to have such a program. Any healthcare practice can become the target of a fraud investigation!

The following steps, if followed closely, will get you well on your way to a bona fide compliance program:

Practice Analysis: First, and foremost, it will be necessary to assess the areas of your practice that pose the greatest liabilities. To determine this, you will need to consider the following:

1. Do you provide healthcare to patients who are either employees of the Federal Government who will be filing claims against/with their employers’ carrier, or who will be filing claims under a government contract (e.g., Medicare/ Medicaid)?
2. Do you accept Letters of Protection on 3rd-party liability claims?
3. Do you have high employee turnover?
4. Do you file your billing electronically?
5. Do you out-source your collections?
6. Do you contract with independent practitioners?
7. Do you contract with outside vendors?
8. Have any of your providers been sued for malpractice?
9. What percentage of your billings are denied/reduced?
10. Do you have a mechanism for responding to either denials or reductions in reimbursement?
11. Do you provide ongoing training to billing and collections employees regarding CPT coding and ICD-9 coding?
12. Do you perform background investigations on all employees prior to hire?
13. Do you provide a mechanism for reporting complaints for internal resolution?

Once this assessment is competed, it will be necessary to develop policies and procedures to allow management of each potential liability. The Compliance Manual that we have created addresses those areas that pose the greatest liabilities for the largest number of providers. It is inadvisable to merely implement these policies prior to performing a thorough analysis of your individual practice needs.

For more tips on developing your Healthcare Compliance program to prevent healthcare fraud and reduce healthcare costs, visit us at:
http://HealthCareComplianceTraining.net/