Participating &
Recommended By:
Necessity is the Mother of Invention
Meet
Mrs. Jones
Anti-Trust Statement
Please be advised that any discussion which leads to an agreement as to price
among competitors is a “per se” violation of the Sherman Act. Providers gathered in
any setting must always exercise caution to avoid discussions or exchanges of
information with their competitors on prices or pricing at meetings since such
discussions or information exchanges may give rise to inferences of agreement.
Any agreement not to compete among business firms is also a “per se” violation of
the antitrust laws. Thus, no discussion of division of territories or customers, or
limitation on nature of business, should be held at any function. Joint refusals to
deal (boycotts), including discussions of blacklists, are likewise unlawful “per se”,
and no discussions related to these practices are permitted.
Discussion of fees by ChiroHealthUSA or examples used are for instructional
purposes only should not be considered as a recommendation for any provider or
group of providers.
The 5 Most Dangerous Things We Face with
Billing, Coding, Documentation,
Discounting & Collection Policy
There are REAL risks, fines and penalties involved with:
1. Dual Fee Schedules
2. Improper Time of Service Discounts
3. Inducement Violations
4. Anti-kickback Statues
5. False Claims Act
Helping patients is the RIGHT thing to do.
Doing it the WRONG way can cost you.
Avoid!
1. Dual Fee Schedules
• Charging more to insurance companies than you
do to cash patients.
• Considered illegal in many states.
Misrepresents charges to carriers
False Claims Act Violation
May violate Provider Agreements
• Triggers investigations
• Florida
• Geico
Avoid!
2. Time of Service Discounts
• Not defined in many states
• More often not defensible – unreasonable
• Often a cover for a “dual fee schedule”
• Not disclosed to carriers as required
• May not be permissible on federally insured's
•
Avoid!
3. Inducement Violations
• The OIG has stated, “incentives that are only
nominal in value are not prohibited by the
[Inducement Law]”
• No more than $10 per item, or $50 in the aggregate
on an annual basis.
• One free exam, x-ray or therapy is a risk.
7
Avoid!
4. Anti-kickback Violations
A person who offers or transfers to a Medicare or Medicaid
beneficiary any remuneration that the person knows or should
know is likely to influence the beneficiary’s selection of a
particular provider, practitioner, or supplier of Medicare or
Medicaid payable items or services may be liable for civil
money penalties (CMPs) of up to $10,000 for each wrongful
act.
Many states have adopted federal rules/regs
8
Avoid!
5. False Claims Act Violations
The Act prohibits:
• Knowingly presenting, or causing to be presented a false claim for
payment or approval;
• Examples:
• Waiving deductibles or co-payments and not reporting to carriers
• Up-coding for higher reimbursements
• Down-coding based on payer type
• AAPC
Articlehttp://news.aapc.com/index.php/2014/04/undercoding-isno-better-than-overcoding/
“The only thing that remains
constant is change.”
Financial policy 29 years ago vs. today
Heraclitus
• Rules & Regulations have changed!
on the Universe
• Conflicting regulations & opinions = CONFUSION and FRUSTRATION!
• CMS/Carrier advice vs. OIG
• State Boards vs. Federal Regulations
• Provider Agreements vs. HITECH privacy regulations
Discounting your fees can put you at risk…
Unless...you know and follow the rules
An extensive regulatory framework, developed over
decades, at both the federal and state levels of
government affects where and how competition takes
place in health care markets.”
• “Much of the regulatory framework arose haphazardly,
with little consideration of how the pieces fit together.
• DOJ & FTC – 2004!
•
“The only thing that remains
constant is change.”
The Challenge:
• Maintaining a financial and discount policy that maximizes
reimbursement AND minimizes RISK of violating regulations.
Heraclitus
on the Universe
For the Record!
• Not a fan of discounts.
• Should be paid at UCR rates.
• EVERY provider and facility offer discounts as part of MCO/PPO
Agreements. Not a matter of IF we discount, but HOW.
• Faulty system penalizes patients without insurance and doctors for attempting
to help them with health care cost.
• The DMPO model is simply a problem solver.
How About You?…Do You Worry?
•
•
•
•
Dual fee schedule?
Cash discounts?
OIG inducement violations
Is your policy is legal &
compliant at all levels?
If you don’t worry, YOU SHOULD!
Better yet. Know the Rules!
What you’ll learn today…
•
Why most consultants tell you to consult your health care attorney
before offering discounts
•
What the potential risks are when offering discounts
•
The 100% legal way to offer discounts and why these consultants
recommend ChiroHealthUSA
Why Worry? Who Cares What We Charge?
• insurance companies,
• state and federal
payers
• state and federal
regulators
• Violation of terms of
agreement lead to
complaints, audits,
fines, & penalties.
Why Worry? Who Cares What We Charge?
• There has never been a time when we
were under more scrutiny.
Why Worry? Who Cares What We Charge?
2005
67% of claims deemed to be fraudulent.
2008
The OIG proudly proclaimed that for every dollar
they spent auditing healthcare, these recouped
$17 for their investment.
RAC Audits, Probe Audit
2012-2014 Work Plan Includes Chiropractic!
$350 Million Added last year to Health Care Fraud
Investigations = Recoupment = $$
$1.00 = $8.14
So Who Cares?
State Board Actions
DISCIPLINARY ACTION UPDATE
Agreed Settlement of Disciplinary Action was entered
into by Dr. X and the CPBN for violations of
unprofessional conduct (NRS634.018(10).
The charges included failure to collect proper copayment amounts, waiving deductibles and, by office
policy,
having a dual fee schedule, i.e., cash vs.
insurance (NAC 634.430)
probation for two years, pay $10,000 in fines and
reimburse the Board for its costs not to exceed
$5,000.
Discounting and dual fees for cash patients can also put you at risk with your
Provider Agreements as well, like those with BCBS, UHC, Aetna, etc. Many
agreements have specific clauses that restrict this activity.
Reference : Kennedy vs. Cigna
Kennedy v. CIGNA, 924 F.2d 698
(7th Cir.)
Plan sued provider after discovering he
was waiving patient responsibility
obligations.„
Plan argued provision in member’s policy
applied, which provided no payment would
be made for charges which member was
not legally obligated to pay.„
Court agreed with plan. If provider wanted
to receive payment under plan, he must
collect co-payments.
Cases on Waiver
„Feiler v. New Jersey Dental Assn,
467 A.2d 276 (N.J. Super Ct.)
„
Suit by state dental association against
dentist for fraudulent billing practices.
Court found dentist “lied” to payors when he
submitted charge of $100 and only intended
to collect $80 fro payor and waive patient
responsibility.
Court ordered dentist to disclose waiver
practice to all payors so they could make
correct payments based
on actual charges.
State Rules & Regulations
• Time of Service Discount Percentages are
permitted in some states.
• Not always defined!
• OIG indicates 5-15% per 2009 opinion.
• PIP laws in some states prohibit charging
more to PI patients than other patients.
NOTICE:
STATE LAW DOES NOT SUPERCEDE FEDERAL
REGULATIONS AGAINST GIFTS & INDUCEMENTS
AND CHARGING LESS THAN FAIR MARKET VALUE!
Audits are On the Rise…
Are you prepared?
Intent is not create fear but to arm you with facts and tools
to minimize risks.
• Take appropriate steps to minimize your potential risks.
• Remember, compliance is NOT an event…it’s a process.
Financial policies in chiropractic are a MAJOR area of risk
and the EASIEST for auditors and investigators to target as
you’ll see!
Inquiring Minds Want to Know!
How Would You Respond?
Yes to Question 5 = False Claims Act
= Inducement
= AKBS/Referrals
25K
10K
25K
Yes to Question 6 = Violation of Provider Agreement
= False Claims Act
25K
for misstating charges
The only time we offer a discount is when it
is required by mandate, or by contractual
agreement, or a documented hardship.
ROCK SOLID POLICY!
You may be entitled to a network or contractual discount under the following
circumstances:
 If we are a participating provider in your health plan.
 If you are covered by a State or Federal program with a mandated fee schedule.
 If you are a member of ChiroHealthUSA, or any other Discount Medical Plan
Organization we may join. Patients who are uninsured, or underinsured (limited
benefits for chiropractic care), may join ChiroHealthUSA in our office and will be
entitled to network discounts similar to our insured patients. Membership is
$49.00 a year and covers you and your dependents. Ask our staff for more
information.
 If you are eligible & choose a payment plan that allows for “prompt payment”
discounts.
 Patients who meet state and or federal poverty guidelines or other special
circumstances outlined in our “Hardship Policy” may be offered a discount for a
period of time as determined by the clinic. Verification will be required.
Can You Eliminate the Risk?
•
•
•
•
•
YES!
Document Correctly
Code Correctly
Bill Correctly & Collect Correctly
Discount Correctly
How To Follow the Rules
&
Solve the Problem…
1 Fee for Each Service
“Your Fee is Your Fee”
Fee is NOT based on payer type
or source of payment!
Set your ACTUAL fee.
•
•
•
•
•
Based on zip code, all providers.
PI visit - $100
WC visit - $100
Ins visit - $100
Cash visit - $100… and let them know!
Discounts based on contracts or agreements.
Eliminates lets make a deal, confusion, only Suzy
Sunshine can explain!
Keep It Simple & Compliant!
Dr. B. J. Palmer Chiropractic Clinic
Notice
In an effort to maintain compliance with various state and federal regulations, managed care
and preferred provider agreements, as well as billing and coding guidelines, we have adopted
the following financial policies:
Our clinic has established a single fee schedule that applies to all patients for each service provided.
You may be entitled to a network or contractual discount under the following circumstances:





If we are a participating provider in your health plan.
If you are covered by a State or Federal program with a mandated fee schedule.
If you are a member of ChiroHealthUSA, or any other Discount Medical Plan Organization we may join. Patients
who are uninsured, or underinsured (limited benefits for chiropractic care), may join ChiroHealthUSA in our
office and will be entitled to network discounts similar to our insured patients. Membership is $49.00 a year and
covers you and your dependents. Ask our staff for more information.
If you are eligible & choose a payment plan that allows for “prompt payment” discounts.
Patients who meet state and or federal poverty guidelines or other special circumstances outlined in our
“Hardship Policy” may be offered a discount for a period of time as determined by the clinic. Verification will be
required.
As part of our compliance plan, as of _______ our office will be unable to extend any type of discounts other than
those listed above.
Acknowledged By: ________________________________________________________
Date: _________________________________
Info@chirohealthusa.com
How did you determine what your
fees SHOULD be?
•
•
•
•
Flip a coin?
Ask your buddy?
Price fixing?
Many consultants & groups offer assistance with establishing
fee schedules.
• Don’t Use Chiropractic Calculator!!
$100 PI - $50 Cash = $75.00
STOP LEAVING REVENUE ON THE TABLE!
Review Payment Allowances for PI/WC
When Can Fees Vary?
Negotiation Time
• Provider status is exchanged for
negotiated fees
• Your “fee system” may reflect
many different “fees allowed”
within your actual fee system
• Is this a dual fee schedule?
• What makes this legal?
• Contractual, Network-Based
Discount!
98940 – CMT 1-2 Areas
Blue Cross 41.00
Aetna
32.00
Cigna
24.00
You Are Likely Already Discounting
When a patient that has insurance enters your office for care – they are bringing
another “person” to the relationship
Doctor-Insurance Company
Insurance Company - Patient
Patient-Doctor
80% Insurance Company
20% Patient
Initial Visit
Routine Visit
Exam: $120
X-Rays: $130
CMT: $65
97014: $35
CMT $65
97110: $50
97014: $35
97012: $35
Total: $185
Total: $350
Routine Visit
Initial Visit
Exam: $95
X-Rays: $75
CMT: $35
97014: $15
98940: $25.15
98941: $34.86
98942: $42.75
Total: $220
CMT $35
97110: $30
97014: $15
97012: $15
Total: $95
100% Poverty: 75% Discount
125% Poverty: 50% Discount
150% Poverty: 25% Discount
Practices Fumble This Ball
• Offer discounts without
contracts.
• Don’t collect the co-pay or
deductibles .
• Offer deals that violate
contracts, like pre-pay
discounts on covered services.
Does my
financial
policy &
discounts
offered meet
ALL
layers of
regulations?
Safety in numbers?
Not a Defensive Posture!
I’ve always offered discounts.
Everybody does it.
I haven’t been audited
I’m not a target.
It’s too hard to change.
Why use a DMPO?
• Even if your state says you can discount, must
be mindful of federal regulations on
inducements, FMV, and provider agreements.
• Even if your state says you can discount, you
can’t discount at the level you probably are.
• If you join a DMPO, none of this
matters, you have a GREEN light!
• The DMPO fee becomes another
“allowed fee” within your fee system.
Doctor-ChiroHealthUSA
Patient-Doctor
ChiroHealthUSA- Patient
Patient-Doctor
0% ChiroHealth USA
100% Patient
Initial Visit
Routine Visit
Exam: $120
X-Rays: $130
CMT: $65
97014: $35
CMT $65
97110: $50
97014: $35
97012: $3
Total $185
Total $350
Routine Visit
Initial Visit
Capped Fee: $65
Or 20% Discount
Capped Fee: $150
Or 20% Discount
Modalities: $10
Procedures: $20
Re-Exams: $25
Each Film: $15
100% Poverty: 75% Discount
125% Poverty: 50% Discount
150% Poverty: 25% Discount
Provider Benefits
Unlike the Insurance Company ‘Triangle’ where the
Insurance Company dictates the fee schedules;
•
•
•
•
ChiroHealthUSA does NOT set your fee schedule.
You, the Doctor, set your own ChiroHealthUSA fee schedule/discounts.
There is NO cost to the Doctor.
You stay in control with a 30 day opt-out clause & no chance of “silent
PPO activity”.
Provider Benefits
Every card sold is an automatic
donation to Chiropractic!
ChiroHealthUSA is a Proud Supporter
of:
• Chiropractic State Associations
• The Foundation for Chiropractic Progress
• The Congress of Chiropractic State
Associations.
What We Learned Today…
The potential risks involved with offering discounts the wrong
way.
• Potential violation of State and Federal Regulations.
• a false claim may be subject to criminal sanctions under 42 U.S.C.
1320a-7b
• maximum fine of $25,000, imprisonment of up to five years, or both.
• Additionally, a conviction would lead to automatic exclusion from all
federal health care programs.
• You risk your license and your livelihood.
• You cannot practice with peace of mind!
What We Learned Today…
Why most consultants tell you to consult with a health care attorney
before offering discounts in your practice.
They know:
• proper discounting can be complicated.
• state laws vary widely and many states do NOT address discounting.
• Federal laws clearly allow discounting but ONLY in certain “safe harbors”.
• Doing it the wrong way exposes you to risk.
Consulting an attorney is GREAT ADVICE…until you do…
The Bottom Line?
Join a DMPO!
Why?
• There is not ONE single consultant or attorney that can
tell you DMPOs are not legal in EVERY state and
regulated in over 34 states…including Florida.
• There is not ONE single consultant or attorney that can
tell you network based discounts aren’t legal in every
state and aren’t the “industry standard” even for
insurance companies.
• Creative financial policies put us at increased risk.
51
The Bottom Line?
Join a DMPO!
• Patients are ALREADY familiar with networks &
membership discounts. Sam’s Club, AARP & Costco.
• Over 275,000 patients have joined!
It’s not something that
MIGHT work… It DOES work!
• Patients enjoy savings!
• Over 2,500 Doctors eliminate risk, practice with peace of
mind, and help support associations and the
profession..at NO cost to the doctor.
52
You Have a Choice…
• Worry about discount policy or practice with peace of mind.
• Join ChiroHealthUSA…or hire an attorney review ALL financial
policy
• Doing nothing… is NOT an option!
www.chirohealthusa.com
Its the next best thing to writing your own contract…we just did it for
you!
53
Unexpected Benefits
Get paid MORE by using a DMPO.
• Allows you to set fees at UCR vs. what you think patients
can afford.
• Convert Shopper calls into NP.
• Capped fee for NP, Routine Visits
• Transition patients from insurance to private pay…by
keeping OOP expense near co-insurance.
• Out of network doesn’t mean out of luck.
• More families under care with LEGAL family plan.
• Handle high deductible, high co-insurance with ease.
• Details covered in Provider/Staff Training
54
The 5 Most Dangerous Things We Face with Billing, Coding, Documentation,
Discounting & Collection Policy
1.
2.
3.
4.
5.
Dual Fee Schedules –eliminated with network based discount.
Improper Time of Service Discounts – eliminated by collecting
network based discount
Inducement Violations – collection of copays and deductibles
combined with ONLY offering network based discounts
eliminates inducement potential.
Anti-kickback Statues – collection of copays and deductibles and
ONLY offering network based discounts eliminates anti-kickback
potential.
False Claims Act – charging and reporting actual charges instead
of discounted amount avoids potential of a false claims act
violation.
Helping patients is the RIGHT thing to do.
Doing it the WRONG way can cost you.
ChiroHealthUSA Brochures
ChiroHealthUSA
$49.00/ yr.
ChiroHealthUSAPlus $89.00/yr.
CHUSA Providers & Staff
$30.00 a year
Action Steps
Congratulations!
• You’ve just completed the required training!
Next Steps
• Submit your Provider Agreement.
• Expect 1-2 weeks for approval.
• Processed first come first served!
• 1:1 assistance available, email to info@chirohealthusa.com
In-Service Training
• Set up of on-line link for enrollments
• Scripts for cash, underinsured, out of network, Medicare & Federally insureds and family plans!
• Practice with certainty & peace of mind.
• Know that you document correctly, code correctly, bill correctly, collect
correctly, and IF you discount, discount correctly.
• Attitude of BRING IT!
Thank you Mrs. Jones!
It’s Monday morning…
Meet YOUR first new patient
Participating &
Recommended By: