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Chiropractor Owned Multidisciplinary Practices are at a Higher Risk of Audit

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(January 13, 2021):  Over the last few years, we have noted a significant increase in the number of audits initiated against Chiropractor owned multidisciplinary practices.  Typically, these integrated medical practices and clinics employ at least one Chiropractor (typically in an ownership or managerial capacity), along with multiple Doctors of Medicine (MDs), Doctors of Osteopathy (DOs). Physician-extenders such as Nurse Practitioners (NPs) and Physician Assistants (PAs) are also commonly employed in these multidisciplinary practices and clinics.

The purpose of this article is to examine Chiropractor owned multidisciplinary practices which employ MDs, DOs and physician extenders in order to provide a wide range of care and treatment services.  While there are a number of benefits to such a model, both State regulatory entities and Federally-contracted Unified Program Integrity Contractors (UPICs) working for the Centers for Medicare and Medicaid services (CMS) have shown their concern regarding these organizations.  Depending on the jurisdiction, a number of State regulatory entities have questioned the appropriateness of the model itself.  UPICs and other CMS Medicare contractors have initiated (or, in some cases, are in the process of initiating) a review or audit of various claims submitted to Medicare for coverage and payment.

I. Why have Chiropractors Worked to Integrate Other Medical Services Into Their Practice?

While you may disagree, it has been our observation that many Chiropractors have an entrepreneurial spirit.  This has manifested itself in a growing number of Chiropractor owned multidisciplinary practices which provide health care services other than merely those associated with chiropractic care.  Depending on the State, integrating other medical services into a chiropractic practice isn’t always easy – there are often a number of statutory and / or regulatory barriers to be overcome. Examples of the Chiropractor owned multidisciplinary practices we have recently seen have included:

  • Pain management clinics.
  • Multidisciplinary clinics which also offer complimentary and alternative medicine therapy options.
  • Industrial medicine clinics (often focusing on Workman’s Compensation cases).
  • Orthopedic clinics focusing on back injuries, spinal compression problems and victims of automobile accidents.

Chiropractic practices choosing to transition over to a multidisciplinary model have often found that they are better equipped to address the health problems of their patients.  This is often due to the fact that an integrated DC / MD practice typically greatly expands the scope of care and treatment services available to patients. This multidisciplinary approach provides patients with a convenient one-stop care and treatment option.

From a financial standpoint, Chiropractor owned multidisciplinary practices have also found that this business model opens up a number of previously-unavailable opportunities.  As you are aware, only a few chiropractic services qualify for coverage and payment under Medicare.  While private payor plans typically cover a somewhat wider scope of services, many Chiropractors have essentially built their business on cash-pay patients.  The addition of MDs, DOs and physician extenders has permitted integrated practices to expand their scope of medically-reimbursable services, many of which now qualify for coverage and payment by Medicare and  private payor programs.  While there are both patient-care and financial benefits to the integrated, multi-disciplinary model, there are also a number of challenges you should consider prior to setting up this type of practice or clinic.

II.  Challenges to be Considered:

A.     State Regulatory Considerations.

Depending on the State, it may be illegal for anyone other than a medical physician to own a medical practice.  For example, many jurisdictions still prohibit the “Corporate Practice of Medicine.” In such States, it is illegal for a corporation to practice medicine.  Moreover, a corporation cannot employ a physician to provide medical care and treatment services.

Although every State is different, if your State prohibits the Corporate Practice of Medicine, it may be against the law for a corporation or for a non-physician individual (including a Chiropractor) to own or control a physician practice or clinic which provides professional physician services.  Therefore, we strongly recommend that prior to setting up a Chiropractor-owned, multidisciplinary practice or clinic, you should contact a qualified health lawyer to assist you maneuvering through the myriad statutory and regulatory requirements governing this complex area of law.  As a final point in this regard, should you choose to set up an integrated practice or clinic, it is essential that you have a full understanding of both your State’s Chiropractic Practice Act and the Medical Practice Act governing the physicians you intend to employ.

B.    Current Audit Challenges.

Over the last few years, many providers, including Chiropractor owned multidisciplinary practices, have been advised that their claims are being placed on prepayment review or that their prior-paid claims are being be subjected to a postpayment audit by a “Unified Program Integrity Contractor (UPIC), such as Qlarant, Safeguard Services or CoventBridge. [1]  Most of these CMS program integrity contractor audit actions have been generated as a result of data-mining.  Other reasons for audit and / or review have included: patient complaints, competitor complaints and referrals from State Medical Boards.  Regardless of the reason for audit, if your integrated practice or clinic is audited, it is essential that you engage qualified health law counsel to advise you on your options for responding to an inquiry by a UPIC.  For a detailed discussion of the current UPIC audit environment, please see our article titled “A UPIC Audit is Serious Business — Is Your Office Prepared?”  [2]

Prepayment Reviews:  Unlike postpayment overpayment assessments, there is not an effective administrative overpayment process for health care providers placed on prepayment review.  We recommend that you consult with legal counsel if your practice is placed on prepayment review.  There are three points to keep in mind in such cases:

(1) It is often in your best interest to continue to submit claims for review and not hold them.  Even if they are denied, at least you can initiate the postpayment appeals process as soon as possible and hopefully begin to restore cash flow;

(2) It is often helpful to engage qualified health law counsel to review your claims and generate a report that can be sent to the UPIC, pointing out that the claims do, in fact, qualify for coverage and payment.

(3) Think outside of the box—no provider can survive on prepayment review over a long period if a significant portion of their payor mix is Medicare.  Contact your health law counsel to discuss possible options for seeking remedial action to have the prepayment review lifted.

Postpayment Audits: Over the last decade, program integrity contractors (such as UPICs) have aggressively pursued alleged Medicare overpayments from Chiropractors, Physicians and other health care providers around the country.  Specific actions taken have included:

(1)  Using statistical sampling and extrapolation.  While the Medicare Program Integrity Manual sets out the basic requirements for a UPIC to conduct a statistical sampling, these contractors have been known to have deviated from the sampling methodologies proscribed by CMS.

(2)  UPIC reviews have often alleged significant claims coverage concerns.  Identified error rates of 100% by UPICs are not uncommon.  They then seek a full refund of all claims submitted by an individual provide.

(3)  Multiple errors often identified. Due to the massive amount of minute technical requirements imposed on providers, UPICs are often able to identify and allege multiple technical and substantive errors in many of the claims which they review.

Medicare Revocation Actions:  Over the last year, we have seen a sharp increase in the number of Medicare revocation actions taken.  The reasons for revocation have varied but have typically been associated with alleged violations of a health care provider’s participation agreement.  In some cases, the UPIC contractors found that the provider had moved addresses and had not properly notified Medicare.  In other cases, a health care provider was alleged to have not been cooperative or refused to participate in a site visit.  As a participating provider in the Medicare program, your organization must fully meet each of its obligations under the agreement in order to remain in the program.

UPIC Referrals for Civil and Criminal Enforcement:  UPICs are actively referring health care providers to law enforcement agencies such as the Office of Inspector General (OIG) and the  Department of Justice (DOJ) for possible civil and / or criminal enforcement) when a case appears to entail more than a mere overpayment.  However, just because a referral is made doesn’t mean that it will be prosecuted.  In many instances, OIG and / or DOJ will decline to open a case for a variety of reasons (such as lack of evidence, insufficient damages, etc.). 

What Sources of Coding / Billing Data are used by UPICs?  UPICs are required to use a variety of proactive and reactive techniques to identify and confront any potentially improper or fraudulent practices.  As set out in Chapter 2 of the Medicare Integrity Policy Manual (MIPM), UPICs have  utilize a wide variety of data sources. 

III.  Final Thoughts:

Chiropractor-owned multidisciplinary practices and clinics currently appear to be under the proverbial microscope While there is little, if any, action that can reduce your likelihood of being targeted for an audit due to data-mining, there are a number of effective steps that you can reduce your risk of liability if an audit or investigation is initiated.  The design, implementation and adherence to provisions set out in an effective compliance plan can greatly improve your efforts to fully meet your statutory and regulatory requirements under the law.

Healthcare LawyerRobert W. Liles, JD, MBA, MS, CPC, serves as Managing Partner at the health law firm of Liles Parker, Attorneys and Counselors at Law.  Robert represents Chiropractors and other health care providers around the country in connection with UPIC audits, DOJ investigations, State Medical Board disciplinary, and other health law related issues.  Please give Robert a call for free consultation.  He can be reached at:  1 (800) 475-1906.

[1] Qlarant, Safeguard Services and CoventBridge are the current program integrity contractors that have been awarded contracts as Unified Program Integrity Contractors (UPICs) by the Centers for Medicare and Medicaid Services (CMS).

[2]  A copy of this article can be found at the following link.

[3] CMS, Medicare Program Integrity Manual, § 2, available at this link.

Home Health Prepayment Reviews are Increasing. Is Your Documentation Compliant?

January 30, 2013 by  
Filed under Home Health & Hospice

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Home Health Prepayment Reviews by ZPICs Are Increasing.(January 30, 2013):  Are the home health services you are currently providing compliant with applicable coverage, documentation and medical necessity requirements?  Have you carefully reviewed your current caseload to ensure that each patient does, in fact, qualify as “homebound.”  Do you have an effective Compliance Plan in place to assist you with your efforts?  Now, more than ever before, it is imperative that you understand and follow the rules.  Compliance is not optional — it is required of all participating providers.  Home health agencies in Texas, Oklahoma, Alabama, Georgia and Louisiana are under the microscope.  “Zone Program Integrity Contractors” (ZPICs), such as Health Integrity and AdvanceMed appear to have increased their use of prepayment reviews in recent months in an effort to identify and prevent the billing and payment of non-covered home health claims.  We have received a number of calls regarding the use of this audit tool and have worked with many agencies in an effort to have their prepayment review status reviewed and lifted by the Centers for Medicare and Medicaid Services (CMS).  The purpose of this article is to discuss the various types of “prepayment reviews” which may pursued by a CMS contractor.

I.  What is a Home Health Prepayment Review?

From a technical standpoint, a prepayment review occurs when the “Fiscal Intermediary Standard System” (FISS System) is programmed by a Medicare Administrative Contractor (MAC) with an “edit” which effectively suspends a claim for further review and assessment prior to deciding whether or not a claim should be paid.  Prepayment edits are intended to carve out claims which must be individually reviewed to ensure that the services or supplies at issue qualify for coverage and payment. As reflected below, there are various types and purposes of prepayment edits

Automated Edits (CMS Pub. 100-08, Ch. 3, §  “Automated Edits” are not provider-specific.  Rather they are established to carve out any claims which appear on their face to be incorrect.  For example, a claim may indicated a “Place of Service” that would be inconsistent with the type of procedure at issue.  MACs use a process within the FISS System known as an “Expert Claims Processing System” (ECPS) to set up automated edits. The ECPS reviews claims and decides (based on the edits put into place) whether a claim should be paid, denied or set aside for further review.  If a claim is set aside, a request for additional documentation is sent to the health care provider.  Once the documentation is reviewed, a payment decision is generally made.

New Provider/New Benefit Edits (CMS Pub. 100-08, Ch. 3, §3.1B).  “New Provider Edits” are typically provider-specific.  MACs install these edits to assist in their oversight of new health care providers recently joining the Medicare program as a participating provider. According to at least one MAC, new provider edits are often limited to 20 – 40 claims.  This gives MACs and / or ZPICs an opportunity to help ensure that the provider is properly providing and documenting services billed to Medicare.  “New Benefit Edits” are typically put into place when a new Medicare program benefit is extended and the MACs need to monitor the new claims to help ensure that they are being provided, documented, coded and billed correctly.

Provider Specific Probe Edits (CMS Pub. 100-08, Ch. 3, §3.2.2A).  “Provider Specific Edits” typically identify specific claims billed by a specific provider and sets them aside for further review prior to payment.  Many times, these edits are associated with a specific provider that has experienced a problem before or is suspected of having problems with certain claims for services.  When a provider is subjected to a prepayment probe audit, they typically receive written notice of the review.  This type of prepayment review can arise out of a complaint by a patient, another provider or even another payor.  It may also be generated through data-mining efforts which flag a provider due to their billing patterns.  Prepayment probe audits of this type are initially used to examine a relatively small number of claims in order to see if a problem exists.  If a problem is identified, the prepayment probe audit may then be expanded to include all claims – this type of prepayment audit is generally referred to as a “Provider Specific Targeted Review” (TR).  It may also be extended in duration until the provider can show the MAC or ZPIC that they fully understand the medical necessity and documentation requirements associated with those types of services.  When the provider specific probe edits are complete, and it is found that there is a high incidence of inappropriate billing, a provider may be placed on Targeted Review (TR).

Referral Edits.  In some instances, a provider is placed on prepayment review and a “Referral Edit” is put into place.  A provider is subjected to a referral edits as a result of a referral from another state or federal government agency.  For example, a state surveyor may have identified concerns regarding the quality of care being provided and may have asked a MAC to examine certain services for medical necessity and documentation purposes.  If a provider is subjected to a referral edit, they are typically notified in writing that the review is being conducted.  They may or may not be advised of the identity of the referring agency.

Widespread Edits.  MACs will typically install a “Widespread Audit” in situations where specific types of claims have been identified through data-mining and other analyses as likely to be problematic.  Widespread audits may focus on issues such as:

  • Length of stay.
  • Number of visits.
  • Use of certain modifiers.
  • Certain diagnosis codes.  For example, edit 5023T selects home health claims for diagnosis 401.9 (Hypertension) and a length of stay longer than 120 days.
  • Previous denials for a specific beneficiary.  For example, edit 59BY9 selects home health claims due to previous denial related to a specific beneficiary.

Provider Specific Targeted Review (TR) Edits  are implemented against a specific provider.  This type of prepayment review is typically initiated by a ZPIC. It may be partial (typically a percentage of the claims billed will be pulled for audit) or it may complete.  As you can imagine, this type of prepayment review can wreak havoc on a provider’s finances, depending on their payor mix.  Prepayment reviews of this type may be extended in duration.

II.  What Should Agencies Expect Targeted Home Health Prepayment Reviews are Initiated?

We have worked with a number of home health providers placed on targeted prepayment review.  To be clear, there is no “silver bullet” to getting off of this status and having your payments reinstated.  Moreover, there is no administrative appeal process which may be pursued.  In our experience, the best and fastest way to get off of prepayment review is to work with professionals who understand the issues.  Until a home health agency is able to show a ZPIC that you and your staff fully understand the medical necessity, documentation, coverage, coding and billing requirements applicable to these claims, a targeted prepayment review may last up to a year, or in some cases, even longer.  If you need assistance with these compliance issues, give us a call.

Healthcare LawyerRobert W. Liles and other Liles Parker attorneys have extensive experience assisting health care providers placed on  prepayment review or subjected to a post-payment audit.  Should you have any questions, please call Robert for a free consultation.  He can be reached at: 1 (800) 475-1906.