The Centers for Medicare and Medicaid Services (CMS) has revised the Advanced Beneficiary Notice of Non-coverage (ABN) Form. The revised Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. The revised ABN replaces the ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007).

When a physician or supplier has a “genuine doubt” that a service will be covered, they are required to notify the patient of this fact. The ABN form is required to be used for a service that is covered. In the Medicare program, chiropractic coverage is limited to coverage for spinal manipulation by means of the hands or hand-held device. For all non-covered services, a standard letter informing the patient of the non-coverage or the ABN may be used. The Notice of Exclusion of Medicare Benefits (NEMB) form can no longer be used.

The newly revised ABN form may be used at this time; however its use becomes mandatory on November 1, 2011.

The latest version of the ABN (with the release date of 3/2011 printed in the lower left hand corner) is now available for immediate use. Mandatory use of this version begins on November 1, 2011. All ABNs with the release date of 3/2008 that are issued on or after November 1, 2011 will be considered invalid.

The mandatory use date has been changed from September to November to accommodate those providers and suppliers with pre-printed stockpiles of ABNs so that they have additional time to exhaust their supplies of the outgoing ABN.

The newest version of the ABN and the instructions for use can be accessed through this link. There, you'll find:

• forms and instructions
• manual instructions
• implementation announcement

Summary:

The following outlines the significant changes found in the newly revised ABN form.

1. There is a new ABN form that must be downloaded and filled out for your office.
2. For repetitive or continuous non-covered care, notifiers must specify the frequency and/or duration of the item or service. See § 50.14.3 for additional information.
3. When a reduction in service occurs, notifiers must provide enough additional information so that the beneficiary understands the nature of the reduction. For example, entering “wound care supplies decreased from weekly to monthly” would be appropriate to describe a decrease in frequency for this category of supplies; just writing “wound care supplies decreased” is insufficient.
4. Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed in Blank (D). In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted.
   
   

I was recently asked at a Starting Into Practice workshop what types of insurance are needed after graduation.

There are several insurance considerations that need to be made prior to practicing.  Many of the considerations will depend on whether you open your own practice or practice as an associate.

A good resource to use is the NCMIC Starting Into Practice Guide, pages 183-188.  The guide can be accessed through the Starting Into Practice website:  http://www.startingintopractice.com/Resources/Forms/Default.aspx

Here are some of the insurance coverages you will want to consider:

• Malpractice Insurance:  Should be purchased immediately regardless of whether you are starting your own practice or practicing as an associate.  Purchase malpractice insurance as soon as you are licensed.
• Business Insurance:  Purchase immediately if you are starting your own practice.  This insurance will provide coverage for your building (leased or owned), your business personal property, general liability, and usually includes extra expense and/or business interruption coverage.  If you enter into a lease, be sure to examine the insurance requirements very carefully to be sure you are covered properly.
• Workers' Compensation:  Purchase immediately if you are starting your own practice and you hire employee(s). 
• Bonding (sometimes called employee dishonesty):  Purchase as soon as possible if you start your own practice.  This coverage protects against fraudulent activities of employees (example – embezzlement).
• Disability Insurance:  Purchase as soon as possible whether you start your own practice or practice as an associate.  If you sustain an injury or illness and cannot practice for an extended period of time, this coverage will assist by providing a portion of your earnings to help with expenses.
• Health Insurance:  If you start your own practice, you will want to purchase this as soon as possible for yourself and possibly your employees.  If you are practicing as an associate, check to see if your employer provides health insurance.  If not, you’ll want to purchase this as soon as possible.
• Umbrella Coverage:  If you’ve started your own practice and have purchased business insurance, an umbrella policy provides an additional liability limit in excess of your general liability, business auto, and potentially other lines of insurance.
• Life Insurance:  Purchase as soon as possible. If you are starting your own practice and are securing a loan, the lender may require that you obtain life insurance so the debt can be paid off in the event of your death.

The above list may not cover all of your unique exposures.  The best thing to do leading up to graduation is to find a reputable and knowledgeable insurance advisor who can help you put together an insurance plan. 

It will help your advisor if you’ve put together a solid business plan outlining your practice path, whether that is opening up your own practice or practicing as an associate. 

NCMIC does have a staff of experienced insurance advisors who can assist you with all of your business insurance planning! To find out more about business insurance available through NCMIC, click here.

Most of you reading this have a renters or homeowners insurance policy.  One of the major reasons you have an insurance policy is to cover your personal belongings. 

When you purchase a policy, the policy will be issued with a Coverage C – Personal Property limit of insurance. 

What you may not know is that there are some categories of your personal property that carry a special limit of liability – regardless of your overall Coverage C - Personal Property limit. 

The special limits may vary by policy and/or insurance carrier, but the common limitations (based on the industry standard ISO HO-3 policy) pertain to the following personal property:

• Money, Notes & Coins                                    $200
• Securities, Accounts, Deeds, Valuable Papers  $1500
• Watercraft, Trailers, and Equipment               $1500
• Trailers                                                         $1500
• Theft of Jewelry, Watches and Furs                $2500
• Theft of Firearms and Equipment                    $2500
• Theft of Silver, Gold, Platinum Ware               $2500
• Business Property on Premises                        $2500
• Business Property off Premises                        $500
• Electronic Apparatus in Motor Vehicle              $1500
• Electronic Apparatus Used for Business            $1500
     And Not in Motor Vehicle

The good thing is, if any of the above limits look inadequate for your property, they can usually be increased by either scheduling the property (itemizing items and listing specific limits for those items) or increasing category limits by endorsement.

I do suggest discussing your policy with your agent to see if any of your Coverage C – Personal Property special limits of liability are insufficient.  If so, your agent should be able to present you with options on how to increase the limits for proper coverage at the best possible premium.

(Did you know NCMIC Insurance Services can assist you with a renters or homeowners insurance quote?  Our experienced agents work with a variety of national carriers to provide you with the best possible coverage. Contact them by email at agents@ncmic.com or by calling 800-394-1466.)

We see it often.  D.C.s who think they'll never be sued.  Or they think they'll only be sued if there's some huge mistake made.

The reality is quite different. 

Many lawsuits result from simple oversights, poor communication with the patient, or other little things that you never think twice about in daily practice.

So how do you protect yourself from a lawsuit?  NCMIC has many resources available to policyholders, including an 8-point practice saving checklist.  Here are the highlights:

1. Do you have a standard procedure for evaluating new patients?
2. Do you use written letters of notification when deciding NOT to treat a patient?
3. Do you consistently create patient records at the time of treatment?
4. Do you review patient records before treatment?
5. Do you regularly use informed consent forms?
6. Are new techniques closely monitored when implemented in your practice?
7. Does your bedside manner put patients at ease?
8. Do you have a standard procedure for billing - including standard collection letters?

Policyholders can get the complete checklist which includes the rationale for evaluating each of these areas and a section on what to do if a patient sues you. 

Click here to log in and access the checklist!

A news headline caught my attention today, “Woman Wins $2.3m From Former Employer.”  The story goes on to explain that the verdict was issued by a jury for alleged sexual discrimination in the workplace.

Do you currently have your own practice or are you planning to have one in the future? 

Do you, or will you, have employees? 

If you said yes to both questions, please take a moment and read further.

If you have, or are going to have, staff employed at your practice, you may want to consider purchasing Employment Practices Liability Insurance (EPLI).  EPLI is meant to protect against claims arising out of discrimination in the workplace, wrongful termination, sexual harassment in the workplace, and other potential employment related exposures. 

Here are a few reasons why it is important to discuss EPLI with your insurance agent:

• Not covered by your other insurance policies:  Your commercial general liability, malpractice, and workers compensation insurance policies do not cover this type of claim.
• Upward trend in claims:  Claims involving employment related practices are increasing year over year – an assumption can be made that the increase is due in part to our ever increasing litigious  society coupled with poor economic conditions and higher unemployment.  I read an insurance publication that stated you are now statistically as likely (or perhaps more likely  depending on how the numbers are interpreted) to have an EPLI claim rather than a general liability claim.
• You don’t have to do anything wrong to be sued:  An employer that has excellent internal controls and written procedures/handbook in place can still be sued!  You might be surprised to know that you don’t have to do anything wrong to be on the other end of an employment practices claim.  Assuming you’ve done nothing wrong, you won’t be faced with compensatory damages, but you will incur the  cost for your defense.  Defense costs, which can be significant, will be at your expense if you do not have EPLI coverage.

I’d encourage you to discuss EPLI insurance with your insurance agent.  Several companies offer EPLI and policies may differ with respect to the exposures they protect against.  There are other factors to look for such as whether defense costs are in or outside the limit of liability, if it includes third party coverage, whether there is a deductible, and, of course, premium cost. 

(NOTE: Did you know that NCMIC Insurance Services can help you with an EPLI policy? Our experienced agents work with a variety of leading carriers to provide both business and personal insurance to D.C.s.)

When I was brainstorming for a topic for my first blog, I thought I’d start with one of the simplest pieces of advice I could provide you as a tenant, homeowner, and/or business owner:  take an inventory of ALL your belongings.

Why?

I certainly hope that you never have to experience a burglary or devastating fire, but if you did, could you recall from memory exactly what you lost?  Could you provide any proof of ownership to your insurance company for valuable items? 

That's why it is extremely important to prepare an inventory of your property. 

Before you gasp at my ridiculous advise (because who has the time or patience to go through and write down everything they own!), I am not suggesting a written inventory.  What I do suggest is a video inventory of your residence and/or business. 

Because a video is both visual and audible, it will allow you the opportunity to describe your property (model, serial numbers, etc.) while you are visually capturing it. 

Since you, the insured, are responsible for providing an inventory after an insured loss, the video inventory can help you remember what you had AND serve as proof of ownership (particularly for the valuable items) for the insurance company. 

Here's how you can easily get started:

• Take a video inventory of your residence and/or business. Walk room to room taking time to open cupboards, storage containers, closets, etc. to capture the items inside. Take time to audibly describe items of value.  Example:  when taking video of your big screen TV, read aloud the manufacturer, model, size, etc. so you have the details captured on your video.  
• Make sure to periodically update the inventory.  Since you will likely be continually adding to or getting rid of property, you will want to update your inventory periodically, perhaps on an annual or semiannual basis.  In between your regular updates you may want to make a  special note if you acquire something of value.
• Keep a copy on premise and another copy off premise.  In the event you sustain a catastrophic loss at your home or business, you want to be sure that you still have access to a copy of your inventory.  You might consider storing a copy in a bank safety deposit, a friend’s  home, at you place of work or check with your insurance agent to see if he or she would be willing to store this for you.  Also, if you store the video on your computer, you may be able to back-up your data to an off premise service.

Now's the perfect time to get started on your inventory.

For the last month, almost 70% of my existing patients have been coming in with new insurance cards.  Even if they are the "same" insurance, they may and usually do have a "different plan" and sometimes the patient may not be aware of this.

As I wrote in a previous blog, most of the billing arguments happen when a patient is billed for and has to pay out of pocket for something they thought would be covered.  Granted, they are signing paperwork in the office explaining their financial responsibilities, but do you really want to deal with disgruntled patients? 

Don't forget, the angry patient tends to be more vocal when it comes to spreading bad word of mouth.

So what I recommend and what I do is to set aside a few extra hours in the week for the office staff to make some phone calls and find out if any changes were made to the insurance plan.  I have someone stay a little longer between the afternoon and evening shifts to make some calls so that I am not short-handed with CA's and taking care of patients.

This does not mean that you need to call every patient's insurance! 

I have a 3-ring binder with copies of insurance cards so when we see a similar card or they have the same employer, we can have a good idea of the coverage. 

Granted, the patient is ultimately responsibe for knowing what their coverage is.  However, I find this little extra effort on the part of the office to be service oriented and it helps avoid frustrated patients who have no idea about their coverage. And sometimes, the patients think that we as providers are part of the whole health insurance problem!

Hope all are having a great beginning of the year!

The world of healthcare is changing right in front of our eyes. I often get asked from patients and other providers, what should we expect next?  If I could answer that I probably would be on Capitol Hill right now. 

At this time I don't know how things will change, but I do know that there will be changes that will affect how we treat patients and how we get reimbursed for services we provide. 

For example...in my area of Pennsylvania, one of the largest insurance providers decreased reimbursement 50% for manipulation and limited us to 1 therapy per date of service, at a rate of $10.  The insurance will reimburse the provider between $2-$27 (this total includes the patient's responsibility, which typically is between $10-$35).  

All the while insurance premiums are at historic highs. 

If you're reading this and think you aren't worth more, you're wrong.  Our drug-free, hands-on approach to healthcare is worth much more.  We, as chiropractors, spend a significant amount of time with our patients to provide care that they can't find in allopathic healthcare. We diagnose, treat, and manage pain for patients. 

If that doesn't say it all, I don't know what will. 

What to do next?  That's a question I have been asking myself for the past 3 months since this change has been implemented.  We decided, as an office, to stay in network with the above-mentioned insurance plan partly because out-of -network benefits are the same and we really have no other choice.  

I see it as doing 1 of 3 things...

1. Get out of dodge
2. Fight with the insurance companies, or
3. Join forces

I suspect in the near future joining forces with other healthcare providers or chiropractors will be a viable option to help defray the cost of overhead, insurance, payroll, etc. 

I don't want to paint a picture of doom and gloom but we have to accept the things we can not change and try to change the things we can.  Where will it stop?

Medicare announced that it will begin increasing audits of chiropractors, aimed at eliminating payment error, waste, fraud, and abuse in federal programs. The national program is part of Executive Order 13520, entitled "Reducing Improper Payments," which President Obama signed into law November 20, 2009. 

This law stems from a 2009 report by the Office of the Inspector General (OIG) and expands provisions of the Medicare Comprehensive Error Rate Testing (CERT) program.  In the report, the Office of Inspector General found that 47% of the claims submitted by chiropractors were "fraudulent."  This was for maintenance care, poor or no documentation and upcoding.

Beginning August 2010, CERT contractors will request records from chiropractic offices as part of a special studies request.  The special studies requests will use targeted samples, focused scripts and, rather than the usual 75 days to comply, you will only have 30 days. 

If you don't reply, they will get the money back!

The only way you can be assured of having proper records is to conduct internal auditing.  This is usually done by a Certified Medical Compliance Specialist.

I received my certification in 2007 and have seen a significant increase in requests for chiropractic records by Medicare and other carriers, over the last six months.  Recently, the Office of Inspector General stated that for every dollar they spent auditing a health care worker, they recouped $17.  For additional information on lowering improper payments, please reference the following website: http://paymentaccuracy.usaspending.gov/

To read the full version of this article, please access the following website:
http://www.wpsmedicare.com/part_b/publications/2010_0726_chiroreview.shtml

To our many new graduates, congratulations! Although it is a time for celebration, it is also time to get the machinery rolling to get you "Started into Practice."  Unless you are going to go backpacking in Europe, the time to begin the credentialing process is now. 

Here, in order, are my recommendations to get you to the point of seeing a patient.

1. Apply for your state license as soon as possible. Many times states will let you apply prior to graduating, and then they will place your application on hold until your transcripts are sent over by your chiropractic college. Request that your chiropractic college send your transcripts ASAP.
2. Call NCMIC to get your malpractice insurance. Once you get your policy number and/or the declaration page you can then move on to the next step.
3. Apply for your NPI number. The application will take about 20 minutes to fill out and it is best to do this online. Type 1 NPI is for you the individual practitioner. If you are going to incorporate, then you will also need a Type 2 NPI number.
4. Once you have all of the above, apply for your Medicare approval. Before you see a Medicare patient, you must apply for approval from Medicare. It is illegal for a chiropractor to opt out of Medicare. If you see a Medicare patient, you must be approved by Medicare to do so. The 855i is for you and if incorporated, also submit the 855B for your corporation. If you are going to be an employee associate you would get the 855R. It is illegal to work under another doctor's numbers. The application is 30 pages and must be downloaded, filled out and snail mailed in to CMS. The approval will take three to five months, however while your application is being processed you can see Medicare patients. Hold all claims for the Medicare care until you are officially approved. Once you get your numbers from Medicare, then you can send in your claims.
5. Call the customer service department for any PPO contracts you wish to participate. Read the contracts carefully. Do not off-handedly sign every contract. If the contract is not to your liking, then forget them. Check the in-network coverage and the out-of-network coverage. I have found a major PPO carrier that actually has better coverage for out-of-network than in-network!
6. Last, check back frequently to the Starting into Practice blog to stay informed and involved!

Good Luck!