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Mitigating Risk Through Proper Documentation Mario Fucinari DC, CCSP, APMP, MCS-P, CPCO

Certified Professional Compliance Officer (CPCO)

Certified Medical Compliance Specialist (MCS-P)

Presented by NCMIC

Disclaimer: The views and opinions expressed in this presentation are solely those of the author.

NCMIC and Mario Fucinari DC do not set practice standards. We offer this only to educate and

inform. The laws, rules and regulations regarding the establishment and operation of a healthcare

facility vary greatly from state to state and are constantly changing. Dr. Mario Fucinari does not

engage in providing legal services. If legal services are required, the services of a healthcare attorney

should be attained. The information in these seminar slides is for educational purposes only and

should not be construed as written policy for any federal agency.

NO RECORDING OF ANY TYPE ALLOWED

This Material is Copyright Protected

Unauthorized Audiotaping or Videotaping or Distribution of any presentation materials is illegal.

LEGAL NOTICE: The information contained in this workbook is for educational purposes and

is not intended to be and is not legal advice. Audiotaping and/or videotaping are strictly

PROHIBITED during the presentations. The laws, rules and regulations regarding the

establishment and operation of a healthcare facility vary greatly from state to state and are

constantly changing. Mario Fucinari DC does not engage in providing legal services. If legal

services are required, the services of a healthcare attorney should be attained. The information

in this class workbook is for educational purposes only and should not be construed as written

policy for any federal or state agency. All clinical examples are based on true stories. The patient

names in the clinical examples have been changed to protect the innocent. No part of this

workbook covered by the copyright herein may be reproduced, transmitted, transcribed,

stored in a retrieval system or translated into any language in any form by any means

(graphics, electronic, mechanical, including photocopying, recording, taping or otherwise)

without the expressed written permission of Mario Fucinari DC. Making copies of this

seminar workbook and distributing for profit or non-profit is ILLEGAL. Mario Fucinari

DC assumes no liability for data contained or not contained in this workbook and assumes no

responsibility for the consequences attributable to or related to any use or interpretation of any

information or views contained in or not contained in this seminar workbook.

CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly assume any

liability for data contained or not contained in this seminar workbook. This seminar workbook

provides information in regard to the subject matter covered. Every attempt has been made to make

certain that the information in this seminar workbook is 100% accurate, however it is not guaranteed.

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About Dr. Mario Fucinari, DC, CCSP, CPCO, MCS-P, MCS-I

• Graduate of Palmer College of Chiropractic - 1986

• Currently in Full Time Practice in Decatur, Illinois

• Certified Chiropractic Sports Physician (CCSP) – Logan College of Chiropractic

• Certified Insurance Consultant - Logan College of Chiropractic

• Certified Medical Compliance Specialist Physician

• Certified Professional Compliance Officer – CPCO (AAPC)

• Post-graduate Faculty of Palmer College of Chiropractic, NYCC, D’Youville College,

Life West and Western States Chiropractic College

• National Speaker’s Bureau for NCMIC, ChiroHealthUSA and Foot Levelers and many state

associations

• Past President of Illinois Chiropractic Society (ICS)

• Chairman, ICS Medicare Committee

• Member Medicare Carrier Advisory Committee

• ICS Chiropractor of the Year 2012

• Member of ACA and ICS

New information posted regularly at

www.facebook.com/askmario and “Like” us

Chiropractic Under Scrutiny

CMS Should use Targeted Tactics to Curb Questionable and Inappropriate Payments for

Chiropractic Services

http://oig.hhs.gov/oei/reports/oei-01-14-00200.asp

HUNDREDS OF MILLIONS IN MEDICARE PAYMENTS FOR CHIROPRACTIC SERVICES

DID NOT COMPLY WITH MEDICARE REQUIREMENTS

https://oig.hhs.gov/oas/reports/region9/91402033.pdf

Strategic Health Solution

• Strategic Health Solutions has been contracted to perform and provide medical review

functions of Medicare and Medicaid programs.

• Strategic Health is currently performing medical review of records through the project

Y4P0434 for Chiropractic Services.

• Documentation will be reviewed for compliance on such issues as medical necessity,

maintenance care and signature requirements.

• CMS will direct claims adjustments and recoupment efforts.

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Look up your profile at : http://graphics.wsj.com/medicare-billing/

THE COMPLIANT OFFICE

Step One: Risk Analysis

Compliance Program Manual for the Chiropractic Office

by Mario Fucinari DC, CPCO, MCS-P

Step-by-Step Procedures to compliance

www,Askmario.com

Front Desk Procedures

Revalidation Required with Medicare

The Medicare Card

CMS has released images of the newly designed and

renamed Medicare Beneficiary Identifier (MBI) card.

The new MBI card will be introduced on April 1,

2018. The card will go through a transition period

from April 1, 2018 through December 31, 2019 as

more than 44 million beneficiaries convert to the new

card with a new identification number. The Medicare

Beneficiary Identifier card will contain a unique,

randomly-assigned 11-character identification number

that replaces the current Social Security-based number.

Each MBI identifier will be randomly generated. An

example of the new identifier would be: 1EG4-TE5-MK73

CMS will begin mailing the new cards to people who receive Medicare benefits in April 2018. The

statutory deadline is to replace all the existing Medicare health insurance cards by December 31,

2019.

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Informed Consent

www.ncmic.com/3806

Informed Consent

This is STATE controlled. Prior to treating a patient, the doctor must provide adequate information

concerning the possible risks, benefits and alternatives to a particular procedure. Doctors must

properly and clearly communicate with their patients. If called into question, documentation of the

communication is vital.

• A general informed consent is recommended.

• Describe the procedures to be employed.

• Disclose the risks of treatment

• Inherent – foreseeable risks typically only be listed, unless the state determines otherwise.

• Answer any questions for the patient

HIPAA

HIPAA General Rule 164.502

A covered entity may not use or disclose protected health information except as permitted or

required by this subpart or by subpart C of part 160 of this subchapter.

Covered Entities (160.103)

• Health Plans: A plan that provides or pays the cost of medical care. Includes Medicare,

Medicaid and self-funded plans. Does not include plans with less than 50 participants

administered by the employer.

• Providers: A provider of medical or health services that transmits ad health information in

electronic form

• Clearinghouses: Process health information from a non-standard content into standard data

elements or to a standard transaction. Does not include third party administrators.

Use and Disclosure of PHI

• Uses – information shared within the covered entity.

• Disclosures – sending information outside of the entity

• A covered entity may use/disclose PHI to carry out essential health care functions for TPO

– Treatment

– Payment

– Health Care Operations

Protected Health Information (PHI) includes individually identifiable health information, or

contains enough specific information, that it can reasonably be used to identify the individual. This

pertains to any information whether in electronic, written or oral form. HHS has recently clarified

that this also pertains to photographs of an individual as well as DNA samples. PHI is protected

for decedents also.

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HIPAA Risk Analysis

• Audit of Privacy and Security Policies

• Who is Your Compliance Officer

• Policies and Procedures of Protection

• How to File a Complaint

• Privacy Policy Updated?

• Privacy Policy Posted?

• Consent to Use PHI

• Patient Authorization for Release of Info

• Accounting Log of Records Request

• Business Associate Contract

• Staff Training Attestation

• Data Recovery Plan

• Emergency Plan

Cybersecurity:

• Social media

• E-mail phishing

• Ransomware

• Where is your vulnerability?

– Networks, systems, or applications;

• Note, learn and train staff about how Ransomware originates;

• Determine how the incident occurred (e.g., tools and attack methods used, vulnerabilities

exploited).

HHS has issued new guidance required by HIPAA that can help organizations prevent, detect,

contain, and respond to threats, including:

• Conducting a risk analysis to identify threats and vulnerabilities to electronic protected

health information (ePHI);

• Establishing a plan to mitigate or remediate those identified risks;

• Implementing procedures to safeguard against malicious software;

• Training authorized users on detecting malicious software and report such detections;

• Limiting access to ePHI to only those persons or software programs requiring access; and

• Maintaining an overall contingency plan that includes disaster recovery, emergency

operations, frequent data backups, and test restorations (all are required standards of

HIPAA to be in compliance).

Communication Plan

• Training

• P&P

• What are the consequences of violations?

• What is the monitoring plan start date?

• All employees must be aware that they are being monitored

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Annual Review

• How often will you review your HIPAA P&P?

• Education and Training plans?

• Staff training?

The Consultation

Documentation must be legible

Medicare Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity

for manipulation. This documentation includes, but is not limited to, relevant medical history,

physical examination, and results of pertinent diagnostic tests or procedures.

The Episode of Care”

Medicare Initial Encounter Report

Symptoms causing patient to seek treatment

Family History

Past Health History

(Social History)

Mechanism of Trauma

Quality and character of symptoms/problem

Onset, duration, intensity, frequency, location and radiation

Provoking and Palliative Factors

Prior interventions, treatments, medications, secondary complaints

Treatment Plan

− Recommended Level of Care

Duration and frequency of visits

− Specific Treatment Goals

What are you trying to accomplish?

− Objective measures to evaluate treatment effectiveness

How do you know when the treatment has been accomplished?

− Care Plan

Treatment Plan:

1. Treatment Frequency

2. Treatment Goals

a) Short-term Goals

To decrease pain, spasms and edema

Resolution of any radicular pain in the lower extremity

Low back pain consistently less than or equal to 6/10 with all activities

Resting low back pain with less than or equal to 2/10

Independent with basic self-care ADL without increased low back pain

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b) Long-term Goals

Address their ADL

Low back pain at worst less than or equal to 4/10 with all activities

Patient will ambulate 15 minutes at 2.0 miles per hour without increased low back pain

Bilateral hip flexion, multifidus and gluteal strength to 4+ to 5/5

Independent self-management

To prepare the patient for a home-based exercise program

3. Care Plan

Example:

In the acute stage: manipulation, EMS (unattended), ice, pulsed ultrasound and patient education

as indicated

In the sub-acute stage: manipulation per palpation, skilled therapeutic rehabilitation exercise to

improve functional capacity, strength and endurance and to decrease pain with ADL and patient

education as indicated

Specific Treatment Goals

What are you trying to accomplish?

Objective measures to evaluate treatment effectiveness

How do you know when the treatment has been accomplished?

Recommended Level of Care

Duration and frequency of visits to accomplish the above goals

Evidence-Based Outcomes Assessment Tools

Why Outcomes Assessment?

• An objective measure of the patient’s status

• Provides objective documentation regarding the patient’s condition.

• Helps the doctor, patient and insurer to make informed decisions

• A deterrent to malpractice

• Backed up by refereed journals (JMPT, Spine)

Outcomes Assessment Tools

• Have patient complete on initial exam, on re-exam as clinically indicated and at any

exacerbations.

• These tests quantify the amount of patient deconditioning present.

• A measure of the patient’s functional impairment of activities of daily living.

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Outcome Assessment Tests

• Visual Analog Scale

• Pain Drawings

• Revised Oswestry Low Back Pain Disability Questionnaire

• Roland-Morris Disability

• Neck Pain Disability Index Questionnaire

• Headache Disability Index

• Bournemouth Questionnaire – Cervical and Lumbar. “Lifestyle illnesses”

• Zung Psychological Assessment Questionnaire

Neck Pain Disability Index Score

0-8% = None

10-28% = Mild

30-48% = Moderate

50-68% = Severe

>70% = Crippled

Revised Oswestry Score:

0-5% = None

6-20% = Mild

20-40% = Moderate

40-60% = Severe

60-80% = Crippled

80%+ Bed Bound

*If you compare the original score to the score at re-examination, there must be a minimum of a

30% decrease in score to be clinically significant.

Assessment – What do you think?

• Provider records their professional opinions and judgments as to the patient’s diagnosis, their

progress and/or their functional limitations.

• You interpret the data presented in the objective portion of the note.

• You may also point out inconsistencies, justify your goals, discuss emotional status or indicate

progress in therapy.

• You may also present reasons why certain information was not obtained or deferred.

• Recommendation of further tests or treatment that you think is necessary.

• Recommendation of referral to another provider.

• Do not introduce new data here.

• This is the area where you record your thought processes and concerns.

Medicare Medical Necessity

1. The patient must have a significant health problem in the form of a neuromusculoskeletal condition

necessitating treatment, and the manipulative services must have a direct therapeutic

relationship to the patient’s condition. (Medicare does not pay for pain).

2. You must have a reasonable expectation of recovery or improvement of function.

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3. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. A

diagnosis of pain is not sufficient for medical necessity

What is Medical Necessity? In your assessment, answer the following:

How is the patient improved?

Why does the patient still need care?

Acute subluxation - treatment for a new injury, identified by x-ray or physical exam. The

treatment is expected to improve, arrest, or retard the patient’s condition.

Chronic subluxation - A patient's condition is considered chronic when it is not expected to

completely resolve (as is the case with an acute condition), but where the continued therapy

can be expected to result in some functional improvement. Once the functional status has

remained stable for a given condition, further manipulative treatment is considered

maintenance therapy and is not covered.

An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is

causing significant interference with activities of daily living due to an acute flare-up of the

previously treated condition. The patient’s clinical record must specify the date of occurrence, nature

of the onset, or other pertinent factors that would support the medical necessity of treatment. As with

an acute injury, treatment should result in improvement or arrest of the deterioration within a

reasonable period of time.

Maintenance Therapy

▪ Once MMI has been reached, Medicare will NOT pay for maintenance or supportive care.

___ Maintenance therapy includes services that seek to prevent disease, promote health and

prolong and enhance the quality of life, or ____ maintain or prevent deterioration of a chronic

condition. When further clinical improvement cannot reasonably be expected from continuous

ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature,

the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit

Policy Manual, Chapter 15, Section 240.1.3A)

1.

2.

“The Episode of Care” Model

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Did you do PQRS in 2016? _____ If no, subtract 2%

Did you do an attestation for Meaningful use in 2016? _____ If no, subtract 3%

This is the NEW amount charged to the patient. ____________________

In 2018, sequestration continues. An additional 2% will be deducted from your payment.

Medicare Part B

• In 2018 the deductible will be $183

• Only covered services are applied to the deductible

• Co-insurance: 20 percent.

• It is illegal to waive ANY part of the deductible or coinsurance

Fraud

Knowingly and willfully executing, or attempting to execute, a scheme or act to defraud any

health care benefit program or to obtain by means of false or fraudulent pretenses,

representations or promises, any of the money or property owned by, or under the custody or

control of, any health care benefit program.

Abuse

Abuse may, directly or indirectly, result in unnecessary costs to a health care benefit program,

improper payment, or payment for services that fail to meet professionally recognized

standards of care, or that are medically unnecessary. Abuse involves payment for items or

services when there is no legal entitlement to that payment and the provider has not

knowingly or intentionally misrepresented facts to obtain payment.

Offering Gifts and Other Inducements to Beneficiaries

(OIG Advisory Opinion 2002)

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. The statute defines

“remuneration” to include, without limitation, waivers of copayments and deductible amounts (or

parts thereof) and transfers of items or services for free or for other than fair market value.

The OIG has interpreted the prohibition to permit providers to offer beneficiaries inexpensive gifts

(other than cash or cash equivalents) or services without violating the statute. For enforcement

purposes, inexpensive gifts or services are those that have a retail value of not more than $10

individually, and no more than $50 in the aggregate annually per patient.

Similarly, there is no meaningful statutory basis for a broad exemption based on the financial need

of a category of patients. The statute specifically applies the prohibition to the Medicaid program –

a program that is available only to financially needy persons. The inclusion of Medicaid within the

prohibition demonstrates Congress’ conclusion that categorical financial need is not a sufficient basis

for permitting valuable gifts.

This conclusion is supported by the statute’s specific exception for non-routine waivers of co-

payments and deductibles based on individual financial need. If Congress intended a broad exception

for financially needy persons, it is unlikely that it would have expressly included the Medicaid

program within the prohibition and then created such a narrow exception.

www.ChiroHealthUSA.com

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Florida Statute

In 2009 the Florida legislature passed a bill creating Florida Statute (F.S.) section 456.0635 with

the purpose of preventing heath care fraud and which establishes penalties for health professionals

involved in such fraud.

Licensed health care professionals and license applicants in Florida should familiarize themselves

with F.S. 456.0635 and the implications that it has for their careers. The statute covers a broad

realm of violations including those which evidence a propensity for one to commit health care

fraud including non-health related fraud and drug-related convictions and pleas. The impact of the

statute on license holders (including renewals) and license applicants is significant and should not

be underestimated.

Medicare & Medicaid Fraud Convictions’ Effect on Licensure

456.0635 Health care fraud; disqualification for license, certificate, or registration.—

(d) Has been terminated for cause, pursuant to the appeals procedures established by the state,

from any other state Medicaid program, unless the candidate or applicant has been in good standing

with a state Medicaid program for the most recent 5 years and the termination occurred at least 20

years before the date of the application; or

(e) Is currently listed on the United States Department of Health and Human Services Office of

Inspector General’s List of Excluded Individuals and Entities.

Qui Tam/Whistleblower

Must have a whistleblower policy

• Non-Retaliation policy

• Who do they respond to?

- Management;

- Compliance office; or

- Compliance hotline

Whistleblower Policy (WP)

• Positive employee relations and morale are achieved best when they are in a working

atmosphere of ongoing open communication between management and supervisors and

staff.

• The employee’s views are important

• The WP will encourage employees to come forward and communicate problems,

concerns and opinions without fear of retaliation or retribution.

• When reporting to the OIG, the person can report anonymously

www.oig.hhs.gov

1-800-HHS-TIPS

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Policy

- Just saying that one has an open-door policy is not enough

- Employees must be given a range of reporting options

• Cell phone has caller id

• E-mail has caller id

• Answering machine

• Forms

• Compliance officer

• OIG hotline

Code of Conduct

• “First among equals”

• Fundamental statement of the organization’s values and standards

• The most public of the organization’s compliance statements

• Demonstrates the organization’s ethical attitude

• Should be written plainly (8th grade level)

• Tailored to the business culture or identity

• Foreign language, Braille, sign language

• Not in the Seven Elements?

The Compliance Program Manual for the Chiropractic Office gives you the tools

you need to plan and execute a customized compliance program that meets federal

standards. The Manual takes you through the procedures necessary to address all of

the standards outlined in the Federal Sentencing Guidelines for an effective

compliance plan. The seven steps of the compliance plan and the Exclusion

Elements are thoroughly discussed with step-by-step procedures to meet all the

guidelines. Available at www.Askmario.com

New information posted regularly at

www.facebook.com/askmario “Like” us

Medicare can now ask for records from up to FIVE years ago. Are you complaint? The OIG

stated that a compliance plan (different from HIPAA) is a mitigating factor against fines and/or

jail time. If you have a Compliance Plan done in keeping with the OIG Recommendations, it may

be your bullet-proof vest! For a professionally created Compliance manual, unique to your office

or chart audits contact Mario Fucinari DC, MCS-P, a Certified Medical Compliance Specialist

and Compliance Consultant for further information. See our list of services at

www.askmario.com or e-mail at doc@askmario.com If you have questions…

www.AskMario.com

E-mail: Doc@AskMario.com

Thank You!!