Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 140

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

“New Documentation Standards”

I will explain how this affects all of us after you read the following article:


Report cites $47B in bogus Medicare claims

By Hope Yen

The Associated Press

Tucson, Arizona | Published: 11.15.2009


WASHINGTON — The government paid more than $47 billion in questionable Medicare claims, including medical treatment showing little relation to a patient's condition, wasting taxpayer dollars at a rate nearly three times the previous year.


Excerpts of a new federal report, obtained by The Associated Press, show a dramatic increase in improper payments in the $440 billion Medicare program that has been cited by government auditors as a high risk for fraud and waste for 20 years.


It's not clear whether Medicare fraud is actually worsening. Much of the increase in the last year is attributed to a change in the Health and Human Services Department's methodology that imposes stricter documentation requirements and includes more improper payments — part of a data-collection effort being ordered government wide by President Obama next week to promote "honest budgeting" and accurate statistics.


Still, the fiscal 2009 financial report — covering the first few months of the Obama administration — highlights the challenges ahead for a government that is seeking in part to pay for its proposed health-care overhaul by cracking down on Medicare fraud.


In recent years, the suspect claims have included Medicare prescriptions from doctors who were dead, and requests for payment for medical supplies such as blood glucose strips for sexual impotence and diabetic shoes for leg amputees. Patients, many of them new citizens who barely speak English, are sometimes recruited by brokers who go door-to-door offering money for use of their Medicare numbers.


According to the report, the Bush administration from 2005 to 2008 reported improper payments of roughly 4 percent in the fee-for-service program, or about $17 billion total in 2008. Government officials at the time, however, typically did not consider a Medicare payment improper if the medical documentation was incomplete or a doctor's signature was illegible. Since these were flaws that ordinarily bar payment, that methodology drew complaints from government auditors that the figures were understated.


For fiscal year 2009, the Obama administration began counting those claims as improper, but was unable to complete an official tally based on the new methodology. As a result, it officially reported improper payments for its fee-for-service program at 7.8 percent, representing a partial tally under the new formula. But it considers the unofficial tally of 12.4 percent more representative.


Beginning next year, the 12.4 percent figure — or a total of $47 billion in improper payments when counting both Medicare fee-for-service and managed care — will be used as the baseline estimate. The federal report sets a target of reducing improper payments in the fee-for-service program to 9.5 percent by next year, which would represent a savings of roughly $9.7 billion.


The Federal Government has changed how it views your documentation to determine fraud.


I just worked with an orthotist (he makes prosthetic limbs) who is part of a federal reimbursement program and the program requires referrals from treating doctors for him to make the limbs for amputees of accidents, health issues and veterans. The federal program requires that he has an original prescription and upon audit, that’s a side story, the federal insurer hired a private company to do the auditing (Sound familiar?) who would get paid if they found FRAUD and add fines to the doctor or have him arrested. They found that the orthotist indeed made over 100 limbs for amputees for this carrier, but had fax prescriptions, not the originals.


Medicare allows faxed prescriptions, as does every other insurer in the nation, but not this federal program and the provider didn’t know this specific rule. Did the orthotist see the patient? Yes. Did the orthotist make the limbs at a cost of over $5000 each to the orthotist? Yes. Did he make a technical error? Yes. Did the federal insurer allow him to fix his paperwork? No. He had to hire a lawyer and is now exposed to over $500,000 in retrospective fees and fines and is being thrown out of the program and may lose his license over nothing but greed on the part of the insurer.


It’s always about the money and you have to do it right. I have written to you over and over to hire an independent auditing company. There are many and I personally recommend Dr. Michael Schonfeld, 516-695-7732 ($500 for the entire audit). In fact, I beg you to get voluntarily audited, as I am getting calls multiple times a week from doctors around the nation who are being retrospectively audited. Dr. Schonfeld's fee is much less than that of a lawyer doing a preliminary conversation with you if audited. The rules are changing too fast for everyone to keep up. To date, not one doctor who has used the auditing service has been anything but very happy with the experience and they have all been able to insulate themselves to a great degree against predator carriers.


2-3 months ago, New York State, after the chiropractic organizations worked tirelessly, was able to get signed a law preventing insurers from looking back more than 2 years. You should all talk to your state chiropractic organizations and get a similar bill passed. It is essential to protect your practice.

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