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Compliance

Implementing a thorough compliance program for your practice is vital.

Specifically, a compliance program which you and your staff can refer to on your computers for clarification, is essential. We've all heard this one before, "If it isn't written down, it didn't happen." Well, this too has changed as a result of advanced technology. In the past, most documentation was merely opinion based subjective information. Basically, it was an educated guess. Today, this would read: "If objective findings of functional impairment and positive outcomes of improvement as a result of objective diagnostic testing are not documented in the patient record, it didn't happen."

Remember, results from diagnostic testing, objective findings and positive outcomes are the requirements for documenting medical necessity. They are the first steps to accessing authorization for treatment and reimbursement.

practice protocols - Copyright – Stock Photo / Register Mark The first visit should include the typical evaluation and management services of the history and examination of the chief complaint, etc. The second visit is when the diagnostic testing is performed. If diagnostic testing is performed on the first visit, the insurance will consider the testing as a component of the evaluation and management service and they will not pay for the diagnostic separately.

Here's what is happening now regarding the importance of compliance. Here in Pennsylvania, Blue Cross Blue Shield (Highmark) has hired a Third Party Administrator (TPA) to manage all of the BC/BS claims for Chiropractic, Physical Therapy and Physical Medicine. If you don't have this in your state now, you will soon. The Third Party Administrator immediately reduced the number of chiropractic and physical medicine visits per year from twenty to eight. Obviously, this was not well received.

But, the reality is that nothing had really changed. Originally, there were twenty visits per year. I call "gift visits." Blue Cross Blue Shield will give the provider twenty "post-payment review" visits per year. Meaning, they will give you twenty visits per year without the provider having to submit the documentation for medical necessity in advance of treatment, i.e. "gift visits."

However, if the patient requires treatment beyond the initial twenty visits, the provider must submit the objective results from diagnostic testing that documents significant objective deficits and functional impairment that establishes the need for continued treatment, i.e. medical necessity. And, the insurance company has the right, at any time, to request the documentation of medical necessity for the first twenty visits for post-payment review.

If the provider cannot submit the required documentation from diagnostic testing to establish medical necessity, a post-payment review audit is likely, which usually results in the return of tens of thousands of dollars for "overpayment" made to the provider. So, the only difference is the "gift visits" have been reduced to eight. And, the documentation of medical necessity for the authorization of additional visits begins with visit number nine. Actually, the eight visit limit significantly reduces the providers liability if it is determined that treatment is not warranted.

Here's the problem. The professional associations are fighting the implementation of this policy. They will lose. Like it or not, the insurance companies have every right to expect and demand the documentation of medical necessity based on diagnostic testing. No other provider group gets "gift visits."

Here's the solution. Rather than fighting the implementation of a reasonable policy, why not ask the question, "What diagnostic testing is acceptable, so we can remain in compliance with your diagnostic requirements?" It's that simple! Comply with the documentation requirements of the insurance reimbursement policy and develop a treatment plan that provides improved outcomes. The end result is a "win-win." Your patient improves as a result of the diagnostic testing, and you get paid.

Update your practice to include diagnostic testing that will comply with insurance documentation requirements and reimbursement policy. Add to your practice, compliance training and a patient case management program, and you will have a practice "makeover" that will stimulate growth and provide access to additional medically necessary treatment for your patients.


William C. Wetmore, DC is a Pittsburgh, PA – based Provider Compliance Consultant. He can be reached at or by calling 412-377-2426.

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