Blog, Chirosecure Live Event August 29, 2021

Recalibrating Your “Its too Good to be True” Alarm

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

Hey everyone, Michael Miscoe with, uh, another Growth Without Risk presentation on behalf of ChiroSecure, happy to be here. Um, this time I’m going to do a, kind of a little, uh, a different kind of topic, uh, all in the compliance realm, of course, but, um, I’ve, I’ve titled this one, recalibrating your it’s too good to be true alarm. Uh, unfortunately I get called upon, uh, to evaluate cases or get involved in provider defense cases in scenarios where in retrospect, um, the doctor realizes that they, um, were taken in by bad information and they did some billing. They made a lot of money. Uh, they got to pay all the money back. They don’t have the money, um, and, and it creates, uh, some very, very, uh, significant situations. Uh, what I call in some cases, unfortunately, practice ending events, uh, because the, uh, value, uh, for the good or service that they paid for, um, that money is gone.

They’re never getting that back. Uh, the money that they received in payments from the insurance company is not all profit of course, but when it has to go back, it leaves a very big hole. So we’re going to talk about some, some things that you need to be on the lookout for. Um, and, and dare I say, uh, predatory marketing, uh, where folks are trying to, uh, I call them get rich quick schemes, but, um, in business B be wary of shortcuts. Um, so tell me if you’ve heard this one. Um, you’ve got, uh, someone coming in pitching, um, you know, some device, a service that you should be offering in your practice. And part of their March marketing pitch is they’re showing you explanation of benefits, um, and showing you how much money you can make. They’re doing profit projections. And that’s part of the marketing, uh, marketing pitch.

When you see that run away, run away very quickly, um, because the EOB is that they show you, uh, it’s, it’s, uh, an old crass negotiating, uh, strategy it’s called power of legitimacy. And, uh, they show you these ELBs to establish the legitimacy of either the coding, the billing, the reimbursement, uh, issue that they’re presenting, um, and without thinking about it, um, you go, wow, they must be paying it. So what these guys are saying or gals are saying must be okay. And if that were true, there’d be no such thing. As post-payment auditing, I would be schlepping traffic tickets for a living or doing something else other than defending, uh, docs and post-payment cases. So just because a payer is paying for it doesn’t mean that they’re knowingly paying for it, understanding what it is that you’re actually doing or billing for. And there has been, um, uh, you know, just a whole host and these things come up over and over and over.

And one of the downsides of being around for as long as I’ve had, as I’ve seen, um, providers, unfortunately get, uh, in very, very difficult circumstances, um, where the, the coding recommendations or the billing rep recommendations they received are just indefensible. There’s just no argument. Um, and, and unfortunately the doc is forced to refund all the money and it creates a very, very difficult situation. So, uh, if you are presented with something like that, and there’s an EOB in it, my first piece of advice, which is free is run. Just forget about it. I don’t care how much money they’re telling you, you’re going to make, uh, just think of it in terms of your one in way from a potential disaster. If you’re really, really curious, um, get an independent analysis, don’t take their so-called, we’ve had legal, you know, review this, get the actual legal opinion, makes re evaluate what it says, have an independent person evaluate it.

So take an explain, uh, potentially some of the legal ease and what issues that lawyer really evaluated. If there’s a coding expert involved, or somebody that’s a certified coder, a biller that’s suggesting that, um, you know, this is all legit, uh, be very, very cautious, um, because, uh, sometimes they are doing incomplete analysis, giving incomplete advice at the behest of the manufacturer who wants to make a bucket full of money. And when the, when all of this goes splat, and, and you’re under the gun to refund money, those, those folks are gone. Um, so they are not going to indemnify you or hold you harmless and pay your way out of this disaster. Uh, you could try and assume I’m involved in one of those cases right now. And, and it’s, it’s an uphill sled. So there’s a number of scenarios. Um, these, these things occur most commonly in the DME realm, um, lumbosacral orthotics, uh, where these get pitched and, um, uh, all of the LSO codes that are in hixpix that’s the healthcare common procedure coding system are for custom fabricated orthotics.

Uh, I I’ve seen people try to bill lumbar support pillows and, and, you know, simple wraparound belts that are not custom fitted. They don’t have all the components, um, that are in the code that they’re using and they pay a truckload. I get it. Um, and, um, and they look very lucrative, but be very, very cautious because that’s money. You’re probably going to have to give back because there are likely not codes for what you’re doing other than an unlisted, a 9, 9, 9, 9. And which the payer is going to say is uncovered. And you get the refund, all the money and all the money that you spent buying, whatever it is that you distributed to your patients that just becomes a loss. Um, there’s a tens units. Um, some folks are still trying to do tens units and, and, uh, I’ve seen all kinds of ridiculous coding on those.

Their build is under a unlisted oxygen supply code [inaudible], uh, especially in auto or work comp cases to be a fee schedule allowances. And that’s going to blow up in your face. I mean, usually I’ve done a lot of fraud work on behalf of payers relative to that, that form of coding, unbundling supplies, Ms. Coding, uh, tens resupplies. Uh, so there’s been a number of folks who’ve been led astray, uh, relative to tens billing, uh, not to mention the medical necessity issues, but you shouldn’t be issuing a tens, uh, as part of a welcome kit to the practice, same thing with LSOE. Uh, not everybody needs one. Uh, and if you’re going to sell one it’s at the end of care, when you have an incomplete result, certainly not at the beginning. Um, the, uh, some other scenarios that I was sent, infrared heating pads, there is crazy markup in these things, and I’m not suggesting that you go, you know, get into it.

Um, but be very, very careful anything that you’re making a lot of money on is going to get a lot of attention from payers. Um, and it’s just a question of whether you want that kind of attention or you don’t, um, beyond that, uh, there’s been some, uh, devices that have been marketed. Uh, they’re they’re FDA cleared, uh, pre-market clearances, they’re electro paricular acupuncture devices, uh, P stem, NSS, NSS bridge, um, where they had some, uh, erroneous coding with the piece stem. They sold the device as an implanted neurostimulator. Obviously the device is not surgically implanted at all. It paid a ton, everybody that got into that, um, you know, especially with Medicare, uh, all that money ended up going back. I mean, certainly you could file appeals, but, um, and, uh, I just recently got a case relative to that, uh, with an OIG subpoena.

So very horrifying stuff you want to stay away from that, uh, with the NSS, that’s a much newer revelation, but, um, the, uh, Medicare audit contractors, the uniform unified program, integrity contractors are on to that. And rather than charging for the device, uh, the recommendations were to bill a 10 day global surgical procedure, uh, for a device that you effectively, you tape the device behind the ear, you tape these little tiny, um, electrode pads that have little tiny, uh, needles in them. Uh, and, and they were billing that as a surgical implantation of an electrode array. Uh, obviously it’s not, um, and again, that’s money you’re just going to have to pay back cause it’s just clearly coded wrong, um, beyond that, uh, I’m sure some of you are familiar with, uh, the Al cat food sensitivity thing. A lot of folks got into that.

Um, and in some states they have rules relative to markup of, uh, uh, of, of testing services, uh, that, that ran people into trouble. But the larger issue was a medical necessity issues and they’re billing like 999 units of this. Um, and the, the billing was rather extreme. People made a lot of money than the boom dropped, and we could go through dozens and dozens of examples of, um, scenarios where, uh, folks have been led into billing things. Uh, one of the more recent ones, uh, regenerative medicine therapy, um, variety of problems there, especially, you know, when you’re trying to bill Medicare some mean, uh, these manufacturers have gotten, uh, CMS to give them, uh, hick picks codes, Q codes, uh, for these, and it, you know, uh, all that does is make it easier for Medicare to find, uh, who’s built for this stuff.

So, you know, be very, very cautious. Uh, we could go through all the statutory rules, why it’s not covered under Medicare, and you may ask why are they paying for it? And it’s because they don’t have an edit. Um, and they’re figuring it out. I have two of those cases where coven bridge is the first you pick, uh, to pick up on that issue. And I’m sure it’s going to spread like wildfire. And pretty soon there’ll be notices on the CMS website, uh, fundamentally, uh, they’re not covered because, uh, they’re not a FDA approved drug or biologic, which means there’s a statutory preclusion to coverage. If you’ve made money on it, you’re going to give it all back. Um, the only way that you have a prayer is if they foolishly, uh, deny the Sur, uh, the, the reimbursement, and it’s not just the, the substance, it’s the injection procedure, it’s the, ENMs, it’s everything associated with it.

But if they denied as medic under the, uh, for reasons of medical necessity, you have an appealable issue there. Uh, but sooner or later, I’ve got to figure the administrative law judge, when you get to that level, going to figure out that it’s not statutorily covered in the first place. And, um, um, that’s going to be the problem there. So some recommendations when you’re presenting some presented with something that looks like it has high profit margin, be very, very cautious. Okay. And this is where I get to the recalibrate. Your it’s too good to be true alarm, as much as you want to believe it, uh, maybe because of COVID or something else, your business is under stress, uh, visitor down, um, income’s down, and you’re looking for a solution to keep the doors open. Be very, very careful because many of these solutions aren’t solutions at all, they’re going to stem the tide for a little bit, but when you get clubbed over the head with a refund demand, uh, and an opinion from me or someone like me that says, doc, the good news is, is you only have to pay all the money back.

They’re not bringing fraud charges or anything like that. I mean, that’s a, that’s a tough day and that’s not a good, uh, fun conversation to have with a physician. I don’t enjoy those at all. So if you see high profit margin or something that looks like it pays really, really well, you know, get it checked out anything that you’re going to introduce into your, uh, practice, get it checked out, make sure you get it checked out for your payers, because most of these consultants are not doing individual payer analysis. They’re not looking at, uh, medical policies from the payers that you bill, they’re not validating the coding recommendations for the payers that you bill. So get somebody who is qualified to do that analysis for you and is going to give you an honest opinion, hire somebody. That’s going to tell you what you need to know as opposed to what you want to hear.

And if it turns out that it’s not a good idea, or that it’s extraordinarily risky, uh, if you go in knowing what the risk is and you’re willing to take the risks, that’s fine. That’s your call. Um, but unfortunately, many of the providers that I’ve had to help through some of these scenarios, you know, we’re completely misled as to the risk. Um, and unfortunately it, it came back to bite them. That’s all we have time for today. Next week, uh, Dr. Sprandel, uh, will be your presenter and I’m sure he’s going to have something fabulous to tell you until next time. We’ll see you later.