Articles August 1, 2014

Risk and Health Care Law

Are there new risks to be aware of considering changing Healthcare Laws?

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act. This law puts in place comprehensive health insurance reforms that will extend four years and beyond. The vision and timeline from 2010, with the inception of a new patient’s bill of rights, to the 2014 goal for all Americans to have access to affordable health insurance options seems daunting. The million dollar question is: What will the impact be to patient care, clinical decision making, documentation, current procedural terminology, billing and disclosure of patient records? Will there be an increase of risk in the clinical setting to reduce cost to Medicare, Medicaid or commercial carriers? The simple answer is no, there should be no increase of risk, with the caveat, are the rules of clinical decision making, documentation, health record dissemination, CPT code usage and billing practices being strictly adhered to.

Most healthcare providers strive to work ethically, give high quality patient care and submit accurate claims for payment. Key notation in the word ACCURATE; free from error, precise, meticulous, faithfully representing or describing the truth. Are you using E&M codes and CMT codes appropriately? Do you truly understand the definition of medical necessity? Do you bill an E&M code with a CMT routinely for each DOS? Have you reduced the actual face to face time for an E&M, with a Medicare patient, because Medicare does not cover this service? Are you only documenting PART, within the initial exam, as opposed to the required elements for a new patient E&M? Are you charging patients over and above the normal and customary fees for an in-network provider service while they meet their deductible? Do you have a lower CASH fee verses an insurance fee for same service? Are you upcoding to meet your overhead needs? Have you waived deductibles or adopted a NOPE standard in your office?

The five most important laws that apply to all Doctors are; the False Claims Act (FCA), the Anti-Kickback Statue, the Stark Law (physician self referral law), the Social Security Act and the US Criminal Code. The Social Security Act, Section 1862 (a)(1)(A) states: “No payment will be made … for items or services …not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member.” Medically necessary care is when the patient has a health problem or condition necessitating treatment, and the services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with treatment.

None of the above requirements, criteria, definitions or elements will be impacted by changing healthcare laws. However, the HHS moved forward on January 17, 2013 and increased the privacy, security and protections for patient health records under HIPPA. The final omnibus rule greatly enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law. NEWS RELEASE January 17th, 2013. Impact of this enhancement is important to your office procedures in HIPPA compliance as well as compliance under the HITECH Act. Here is where risk must be addressed with the changing healthcare laws. WHEN to bill and WHEN NOT TO! WHAT entities can have access to patient health records and when and why they cannot! IT IS TIME for a new document in your standard patient record format; a Restriction on Uses and Disclosure Form.

Most healthcare facilities utilize initial intake forms including a signed statement that allows the healthcare entity to seek payment from an outside payer. However, under the expanded regulation, patients have the right to choose to pay all fees out of their own pocket and by their signature restrict disclosure of their health information; this holds true for a patient within-network benefits. In the event your staff is not clearly educated on the impact of this restriction TAKE NOTE that a generated and submitted bill, to an outside payer, would constitute unauthorized disclosure of a patient’s health information. The contract you signed as am in- network provider is mute against this federal law. Patients who choose to pay full price, not normal and customary in-network fees and sign a restricted disclosure of their health information STOPS the billing process to an outside agency.

Furthermore, with the implementation of ICD-10 there will be significant changes to the way you document. ICD -10 allows and results in a greater tracking of services and accuracy will be essential in documentation and billing. Quote from CDC; ICD-10-CM Official Guidelines for Coding and Reporting 2012- “Whereas ICD-9 employs three- to five- digit codes, ICD-10 codes use three to seven digits.”

It is a dynamic time to be in the healthcare industry. Accurate and complete patient records and documentation of all services and consents is an essential component to minimize clinical risk. Knowledge combined with management of changed healthcare laws for HIPPA and the HITECH ACT will be imperative for complete compliance in a clinical setting. Accusation of non-compliance of HIPPA or the HITECH Act, improper, unskilled, or negligent treatment of a patient can be clearly defended with precise and meticulous documentation. It is important to keep in the forefront of your mind; ‘if you didn’t document it, it’s the same as if you didn’t do it.’

Healthcare laws will continue to expand both at the Federal and the State level. Legal defense for Malpractice as well as Board and Audit defense has become a growing concern for many Chiropractors. Establishing and following a compliance program will help avoid errors and ensure submitting true and accurate documentation and billing. If you are considering a particular billing practice or business operating procedure consult CHIROSECURE. ChiroSecure is committed to providing the exceptional quality protection; you will need, by offering you the Most Comprehensive Coverage available at the Most Competitive Rates. CHIROSECURE will assist your goals of compliance with education and risk management tools to support the healthcare industry demands. It takes an educated and compassionate team to support the goals of a compliant Chiropractic office; count CHIROSECURE as one of your most active and supportive members of your team.

Stuart Hoffman, D.C., F.I.C.A., is the president of ChiroSecure. ChiroSecure offers many policy op¬tions to choose from. For more information, call Dr. Hoffman directly at 1-866-802-4476 or visit