Podcast Transcription

Daniel: Welcome to “The Future Adjustment,” Chiropractic Economics podcast series on what’s new and notable in the world of chiropractic. I’m Daniel Sosnoski, the editor-in-chief of Chiropractic Economics, and our guest today is Ted Arkfeld, DC. He’s a certified professional coder and the director of risk management for Best Practices Academy, but he hardly needs an introduction. Dr. Arkfeld is one of the nation’s leading authorities in chiropractic coding and documentation. He’s authored two textbooks and is a regular presenter at conventions. If you know anyone prominent in the world of coding education, Dr. Arkfeld is probably the one who trained them. And he’s here today to talk to us about the current state of compliance in the chiropractic field. Good afternoon, Dr. Arkfeld.

Ted: Hey, Daniel. Thank you for having me on the podcast today.

Daniel: Okay. Well, it’s our pleasure. Well, you know, one of the things that always comes up when you talk about compliance in coding is the office of the Inspector General who’s had it out for DCs for quite some time now. Can you give us any information on the latest word from the OIG’s office on civil rights and inspectors and auditors?

Ted: Well, the OIG, as you mentioned, has had us on their work plan. And it’s not something we want to be on as a profession. But they have increased their auditors and their investigators, especially the Office of Civil Rights, which that is truly the HIPAA police in today’s health care.

Daniel: In some reading about the current state of the federal government, I’d heard that various offices of Inspector General exist in most federal agencies, as a sort of an internal watchdog and that a lot of them have been defunded and destaffed considerably, 25% cuts and so forth. Is that the same for the one that controls CMS?

Ted: No, not to my knowledge. As a matter of fact, they have found it so profitable with the OIG to watch health care, and their whole task is to eliminate fraud and waste and abuse when it comes to health care. And so one of the stats that I had read was that for every $1 that they pay out in investigation, they receive or recoup $7 back. So it is still a very profitable situation for them to look at us, and I say us as a chiropractic profession, because, unfortunately, we still are the number one health care providers that have coding and documentation error rates. And even though that is getting better, we have dropped that, we still are number one, unfortunately.

Daniel: Right, and to kind of put this in context, the OIG released a statement earlier this year. An auditor’s report was the technical name of that document. And they said that they estimated that they’d paid out something on the order of $900 million incorrectly to doctors of chiropractic. And that was through misuse of the AT modifier. Do remember that paper?

Ted: I do, and it’s nothing new. The AT modifier indicates that when a Medicare beneficiary, Part B patient, or your traditional Medicare, comes into your office that they are exhibiting signs and symptoms of a neuromuscular skeletal condition and that it’s up to us to substantiate our care in that that’s active treatment. Now, where we as a profession get into trouble is that those patients may continue on and care past what the various Medicare carriers believe is reasonable and necessary or falling under the definition of the AT modifier. In other words, we’re still doing too many maintenance and wellness visits. And that’s where most of our post-payment audits are arising from. And that’s where most of the negative post payment audits…and I call them negative because that’s when the doctors have to actually repay money back to the various carriers.

You know, and unfortunately I still see misuse of the AT modifier and the GA modifier, the GA modifier signals that an ABN is on file. And just a quick coding tip, please, doctors, do not put AT and GA modifier on the same claim form. When you do that, you’re signaling that you think the patients is in active care, but, oh, you’ve got an ABN on file. It’s almost like hedging your bets. Well, each of the carrier’s computer system have edits built into it, and those edits will just trigger a red flag. Some of the worst post-payment audits I have been involved with with doctors have been because of AT and GA modifier being on the same claim form.

Daniel: Right, and “Chiropractic Economics,” we report on the dangers of upcoding and downcoding regularly. It’s often the case that a doctor will code in some way hoping that they’ll avoid detection, but now the computer algorithms that the carriers are using are pretty savvy at showing behavior that is abnormal. I know that downcoding and upcoding has been problems with doctors trying to stay under the radar of the various providers’ computer systems. What often happens is they wind up actually raising their visibility by coding in ways that are abnormal and flag themselves. Do I understand it correctly that the AT modifier is to demonstrate medical necessity?

Ted: Well, it’s to demonstrate that the patient is in active care which meets the medical necessity requirements for Medicare. And obviously, the diagnosis goes a long way when your treatment programs are expanded out, you know, maybe past 12 visits. And your documentation must be spot on and support the care that you’re providing for the patient. So there’s a lot of fluid elements going into this thing that we call medical necessity, which the AT is one part of that equation.

Daniel: Right, so, when the patient presents for care, and they’re having an acute episode, it’s appropriate, if possible, to code that with AT. But if the patient at some point transitions to maintenance or wellness care, then you have to stop using the AT modifier. Is this kind of the place where the problems tend to arise?

Ted: It is, and what happens is that the doctors will continue to treat the patients even though they’re in wellness or maintenance care. And they’ll continue to use the AT modifier, and that’s not what Medicare will pay for. And this stems from a lot of different factors. One of them, you know, and it’s a big thing, I think, that plagues the profession is the doctors are trying not to make the patients financially responsible for some of the care that they receive. And that’s the reason I always recommend that doctors need to stay out of the financial relationships with the patients. Give the patients what they need, and then delegate it to a support staff to cover all the financial aspects. And then do a really good job of patient education. Outline what medical necessity is and what Medicare will pay for and what they won’t pay for.

Daniel: That sounds like good advice. And with respect to that OIG report that talked about those overpayments stemming largely from this issue, I was reading that. And I was surprised to discover that what they had done was, essentially, to audit the records of two practices, something on the order of 100 charts. And then they extrapolated from the numbers that were miscoded here. They extrapolated that was probably the size of the overpayment made to the entire profession. That seems somewhat unfair to me. Did it strike you that way as well?

Ted: And this has been going on, the unfair extrapolations have been going on with post-payment audits for years. And so what they will often do is they’ll take a small sample of patient files. And they’ll look at that, and if there’s an error rate, they’ll now go back and extrapolate and say, “Well, we found a 25% error rate on this small sampling. So we believe that over this last two year period, or whatever years that they wanna look at, we believe that there was a 25% error rate on that.” And that’s how these overpayment demands just ballooned into the thousands of dollars. And it’s absolutely not fair and that’s the reason you have to get a health care attorney involved immediately in order to battle on your side.

Daniel: That’s good advice. I definitely reported on that as well. And I understand there’s these people called the Medicare hired guns, the recovery audit collectors or RAC auditors. Are they still out there? Are they still basically collecting commissions on overpayments that they find in practices?

Ted: Yes, they are. It was such a successful trial period for the RACs that they renewed their contracts, and I believe they run through 2018. And you hit it right on the nail. They are hired guns, okay, so their sole means of income is to come in and find overpayments or treatments that are not medically necessary, and then they get a percentage of what they recoup.

Daniel: That sounds pretty frightening. If a RAC auditor shows up on your doorstep, how would you advise the average DC to respond to that?

Ted: Well, first of all, I would say, “Listen, I’ll be happy to meet with you, but let’s arrange a time and a meeting.” And then I would have that DC, you know, get in touch with a health care attorney immediately just to get the ball rolling. Make arrangements. Don’t let them interfere, interrupt your normal daily operations. They can’t just come in. That’s a whole other topic right there. Those are ZPIC auditors, and those guys can come in any tim