Blog, Chirosecure Live Event March 10, 2022

Post-Payment Audit Risk Associated with Long Term Patients

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Hello everyone. My name is Michael Miscoe with Miscoe Health Law. I’d like to welcome you to this week’s installment of ChiroSecure’s Growth Without Risk series of lectures. And today we’re going to regurgitate a topic that we did a couple of years ago regarding Post-payment Audit Risk Associated with Long-term Patients.

So as your practice gets older, you have patients that have been with you for years and years. And the issue arises of when you re-introduce or those patients back into care. It usually happens a couple of ways. Normally with patients with visit limitations, you treat them for their number of allowed visits under the presumption that those visits are covered in medically necessary.

And then when the new year rolls around they magically come back and you start billing again. That creates a rather identifiable and problematic billing profile that usually, excuse me alerts that’s easily identifiable by payers and they tend to pick on those patients the more relevant.

Issues that we’re going to talk about today are the people that have the magical, unlimited visits as long as they’re medically necessary. And there is a pattern of ongoing care and these patients may have visit limits as well. And what you’re trying to do is stretch out their care within their visit.

So that you can get them through the year. So in those cases, let’s say you got a patient with 12 visits. It would be natural if you concluded that, Hey, what, we’ll treat a patient once a month, they’ll get their 12 visits and we’ll get them through the year. And hopefully they won’t need more than that.

The problem with that is, is that visit schedule alone looks like maintenance care because it is and even if the patient presents with mild exacerbations or whatever the condition is neither significant enough based upon the fact that only one visit was given. Nor is it likely that you can claim that you achieved a durable, significant long-term improvement with that single visit, especially when it happens on the second Tuesday of every month.

So that type of care is easily identifiable and you need to be cautious when you’re dealing with patients with. Patients with defined visits and trying to stretch them across the year. And you see these patients for years and years especially if you see them for years and years on that type of visit schedule for the same type of diagnosis, whether it be, subluxation and neck pain, or maybe even something more significant, like a ridiculous or a neuropathy or something of that nature even with an appropriate diagnosis, that pattern of care is going to be easily identifiable.

And it’s going to be difficult to challenge an adverse determination of necessity. So let’s say having understood that concept, you allow patients to come in whenever they want to come in, but when they have a significant mechanism of injury you want to start a new billable course of care, and that is fine.

However if there’s a a mechanism you need to focus on that, develop a treatment plan, update the diagnosis, set your goals and hopefully motivate the patient to follow through so that you can achieve those goals and demonstrate the care is in fact, medically necessary as defined by the. Now the problem is let’s assume all you’ve done that.

You’ve done all of that. And the patient disappears in the middle of your care plan and then magically shows up. Later on and where they’re saying complaints and conditions. And in most cases, when you look at the notes, just pick up where they left off as if nothing happened like that one month or six week or two month break and care didn’t even happen.

And that’s a by-product of EMR systems that allow you to just salt from the last visit, if it’s all the same and you know what it is, and you just continue tomorrow. Unfortunately, however, when you’re looking at that retrospectively and you don’t explain what happened in between moreover, the lack of a mechanism to start a new course of care.

We don’t know how the prior course of care ended. We don’t know why the new course of care is beginning. And as often as the case depending on where you’re geographically located if you’re in Florida, you get patients that are snowbirds. They just show up there for certain fine periods of the year, and then they go away.

Or if you’re in the north, you lose your patients, some of your patients in the winter time. And then when they come back, you can’t just simply pick up where you left. What you need to be thinking about is doing what’s called an interval history, which means you start from the last encounter and you explain what’s been going on over this break in the course of care, in order to reestablish the patient may be even on the same type of care plan, but you have to rationalize why it’s necessary.

You haven’t seen the patient for three months. So apparently they’ve been doing just fine without chiropractic care, or maybe they were getting it somewhere else, but you need to explain that. Why are they back now? Okay. What happened in the past couple of days, past week that caused the patient to return to care and let’s assume your patients aren’t going away on vacation or something and they just stopped care because they thought that they were done regardless of whether you thought they were done or not.

And now they’re back. This interval history has to document, they did fine for X number of weeks, months, whatever. And then this happened. Okay. Because you got to give the payer a basis for. Justifying that the patient needs to come back into care then in your examination. Of course you have to do an examination, but you need to be focused on assuming the patient has the same problem that they had before.

How is it different? Then when your last song. So I don’t really get too wound up about, you did this palpation and you had these finding then that finding and that finding w you already know what the problem is, what your examination should focus on is how is that condition different than when the patient left care before?

So if it’s a true recurrence, which means, a prior condition has reimbursed. And is now a problem again, you already know what it is, so therefore rather than focus on justifying that they have this same problem. Again, you need to focus on that as well as how is it different than it was before.

Beyond that your job is to then think about, okay, is the diagnosis different? And not only from the standpoint of the code, but is this severity has the severity, the condition changed from when the patient was here before. And when you classify your primary objective problems, not only with the diagnosis code, but rate the severity of that condition, it gives you some way of comparing and contrasting, okay.

They were. In, in, in the narrative mild moderate severe, you can use numeric scales to rate the severity of a problem, but it gives you a way to demonstrate that this mechanism or whatever happened between when they left. And now they’re back that, that it has resulted in a worsening of the condition.

And then from that, you can then build a goal in terms of where you want the status of that. To be from a severity perspective when you’re done, you can also use outcome assessment tools, but unfortunately, if the patient left without being discharged from care, you probably don’t have an outcome assessment as of their last visit.

So that becomes a comparative tool that likely won’t help you in that respect, but at least you can establish the degree of impact. Using an appropriate outcome assessment tool at the initiation of this recurrence, and then track it again when you dismiss the patient and hopefully educating the patient, look, you gotta let me finish.

Because when you jet out and we don’t and you leave and you depart on your own, we don’t have a way to classify, how much progress we got so that when you come back and a couple of months, To demonstrate the decline in your functional status. Always thinking about, establishing a discharge date or at least a notional discharge date.

When you establish a plan of care, it helps tell the payer that you have a defined beyond frequency and duration. When you think the patient’s going to be done, and if you’ve been doing this for a couple of days, you probably have some expectation, especially because you have some knowledge of this patient as to what you can actually accomplish.

But it helps set the. It at the outset that you have a defined end point, your plan is not three times a week for four weeks and reevaluate. And then in four weeks, it’s three times a week for four weeks in a reevaluate. And it’s as continuing. I’m just going to keep going until somebody stops me, plan a care or the patient decides they’re done plan of care.

The physician should be in control. You should have, and look, you can establish. Arrange, you think the care is going to take, two to five weeks or three to six weeks or something of that nature, but make realistic projections as to what you think you can accomplish with the care and then establish a discharge date on that basis.

The key thing that I want to get across is that when patients return to care, Especially with the same problems that they’ve always had. Maybe you got patients that have chronic low back pain and they present occasionally and you’re going to take their 20 visits and you’re going to use five here and six there and do definable courses of care as you should.

That’s fine. But don’t forget. Beyond the billing profile, which looks normal that there’s something going on there. The payer’s going to notice that the diagnosis isn’t changing and I’m not suggesting that you arbitrarily change the diagnosis to head fake them. That would be a false statement related to a healthcare matter.

And it’s a title, 18 crime. They have what they have their condition is what their condition is, and if they have the same condition and it’s a true recurrence, don’t be afraid to report it. Just be sure to back up in your documentation, that you know what happened, between when they left. And now that they’re.

Track their history, the history of their symptoms, their functional loss. And as best you can try to identify a mechanism. Now I know that most patients say, I don’t know what happened. I just woke up and I was hurting. Will you did. Something set this off. Talk to me about your activities the day before the, before that, or before that, when did you first start noticing symptoms?

What did you do before that? The mechanism is critical because where there is one and identifiable mechanism, the payer is more likely to be thinking. Care rather than chronic care. They’re more prone to allow for a number of visits for an acute presentation in retrospective review, even though it may not be documented perfectly.

And then once you establish that, if you can set some goals based upon. Your objective problems or your outcome assessment, or both preferably both, where you want to get, you have hypertenicity or ridiculousness that you rate seven out of 10 and your goal is to get it to three out of 10.

That helps establish that you have a specific purpose for the treatment, any way to tell when the patient is done. And that helps you get out of the case when you’re supposed to, if you convert the patient to maintenance for care cash after that until the next major upset. Fine. Be cautious about looking at a patient’s visits, assuming that they’re an entitlement, they’re not they have to be medically necessary and to demonstrate that payers use a whole host of tools.

And one of the most interesting ones is they look at your visit per week average. And when your number’s less than one, that’s bad. If it’s between two and three, you’re good. And that doesn’t mean treat patients two to three times a week until they run out of visits. Because that’s going to be pretty noticeable as well.

Make sure you order appropriate care, get them the benefit that they can get in a shorter visit schedule as possible, and then turn them loose, hopefully to maintenance care for cash until they do something, track the mechanism, take them through another course of care. And at least from a profile perspective you’re going to be less visible in terms of somebody that they might want to audit.

Retrospectively, if you have a visit schedule, that’s very predictable. In a in once every concept it you certainly opened the door to that type of scrutiny and trust me, they will pick. Your worst patients every single time when this happens docos, I know exactly why they picked these patients and, they pick the worst ones.

And they’re patients that have been with you usually for years when they’re looking at medical necessity. So hopefully those little tips will help you. Not only to, put some additional information in your documentation. That will help you in post-payment review and help a payer understand why this person is back, why they’re getting billed for this care and also help you establish what you intended to accomplish with it.

And even for bonus points, what you actually did accomplish with it based upon a change in the severity of the objective problems through re-evaluation next week, Dr. Collins is going to be back with some coding and billing stuff. So I hope that was helpful to you and we’ll see you next time.