The Chiropractic Aide Index

An outline of articles in The Chiropractic Aide:

This article is under regular revision.

Establishment:

Staffing:

Services:

Pricing:

Coding:

Billing:

Collecting:

Payables:

Accounting:

Marketing:

Promotions:

Management:

Informed Consent for Treatment Form

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Simplest as two separate documents:

• Consent to be examined...

1. in the new patient document.
2. Only one sentence, above the patient signature.

• Informed consent to treatment plan...

1. Plan made by doctor.
2. Pricing and payment plan made by registrar.
3. Consent with payment made by patient.

~~~~~~~~~~~~~In your new patient forms~~~~~~~~~~~~~~~~~~

INFORMED CONSENT FOR EXAMINATION

I request and allow the doctor and the staff here to examine me. I understand there is mild risk of increased pain or soreness during my examination.

Signed ~ Pati Ent
Date~ March 2, 2011


~~~~~~~~~~~~~~~~~~~~on your letterhead~~~~~~~~~~~~~~~~~~~~~~~~`

YOUR PERSONALIZED PLAN

Goal for Treatment: ~alleviate backache after a fall Feb 22~
Problem: (Diagnosis): ~back ache from fall~
Expectation (Prognosis): ~good for full recovery in six weeks~

Recommended Treatment Schedule: ~2x weekly for 6 weeks, then re-evaluate~

Chiropractic Care: ~three spinal regions & leg~
Therapy Modalities: ~ yes, each visit after chiropractic~

risks: soreness, fractures, disc injuries, strokes, dislocation and sprains
alternatives: physical therapy only, medication, acupuncture, waiting.

Other notes: ~osteoporosis increases risk of fracture~

INFORMED CONSENT FOR TREATMENT

I understand the risks names above. I request and allow the doctor and the staff here to examine and treat me as described above.

Signed ~ Pati Ent
Date~ March 2, 2011

---------------------------

-

~~~~~~~~~~~~~~~~~~

Cautions on this form:

You need to add something to this if the patient asks specific questions, or has increased risk, say for osteoporosis or prior spinal surgery. Leave margin space for this.




All the best to you and yours.
Gary Shannon

Informed Consent

This post sponsored by
Hands-On Chiropractic and Massage
13033 SE Rusk Rd, Milwaukie OR 97222
503-656-8098 www.weadjustlives.com

Gary Shannon here.

Yes, the Chiropractor has to do this. In writing. Every patient.

Doctors are reluctant to give an adequate "PARQ" (Procedure, Alternatives, Risks and Questions) before treating or examining the patient, even though there are few risks. For the patient it's often just another bit of paper to sign.

Since 1991, Oregon Board of Chiropractic Examiners Administrative Rule 811-035-0005 (2) says the patient has a right to information:

(2) The patient has the right to informed consent regarding examination, therapy and treatment procedures, risks and alternatives, and answers to questions with respect to the examination, therapy and treatment procedures, in terms that they can be reasonably expected to understand.
(a) Chiropractic physicians shall inform the patient of the diagnosis, plan of management, and prognosis in order to obtain a fully informed consent of the patient during the early course of treatment.
(b) In order to obtain the informed consent of a patient, the chiropractic physician shall explain the following:
(A) In general terms, the examination procedure or treatment to be undertaken;
(B) That there may be alternative examination procedures or methods of treatment, if any; and
(C) That there are risks, if any, to the examination procedure or treatment

In addition, your malpractice insurance carriers like doctors to use PARQ in writing and signed by the patient. Litigation attorneys who sue doctors hate them: if the suer signed off that the doctor TOLD them that there is a RISK of the problem they are having after care, and they AGREED to care anyway, they have no malpractice case. Without a PARQ in the file, it's only doctor's memory against patient memory.

ONE INFORMED CONSENT SOLUTION

Avoid all this by creating a template form to include with new patient and new exam papers. The OBCE gives an example of informed consent to new licensees as follows:

~~~~~~~~on your letterhead~~~~~~~~~~~

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, on me (or on the patient named below, for whom I am legally responsible) by the above named doctor of chiropractic.

Though chiropractic treatments are usually beneficial and rarely cause any problem, I understand that, like many other forms of health care, there are some risks. These can include, but are not limited to fractures, disc injuries, strokes, dislocation and sprains.

Alternatives to chiropractic treatment for common musculoskeletal conditions may include physical therapy, medications such as muscle relaxers and anti-inflammatory drugs and acupuncture.

I have has the opportunity to discuss with the doctor the purpose and benefits of the recommended chiropractic care, and alternatives to chiropractic treatment have been reviewed.

I further understand that health care providers cannot guarantee the results of treatment. I acknowledge that no guarantee of the outcome of chiropractic care I have requested has been made. I have had ample opportunity to ask questions, and my questions have been answered to my satisfaction.

Patient's name (printed)_______________________ Date____________________
Signature of patient ______________________________________________

or
Signature of parent/legal guardian _______________________________________
(if patient is a minor)

~~~~~~~~~~~~~~~~~~

Cautions on this form:

You need to add something to this if the patient asks specific questions, or has increased risk, say for osteoporosis or prior spinal surgery. Leave space for this.

If you know of additional risks, such as muscle soreness or dizziness, add them to the list above. There is a gray legal area here: Have all the risks above been verified by Chiropractic clinical trials? Is it acceptable to only list scientifically verified risks? What if the doctor disagrees with the validity of the trial? If the doctor personally and professionally recognizes an unverified risk, should he list it? Must he? These unanswered questions underline the difference between ethics and law. The simplest answer: list everything possible, and explain your opinions about them when asked.

Will patients ask questions because of this form? Usually.
Will patients skip care because of this form? Rarely.

As a patient and administrator, I prefer shorter forms that provide more information. I will provide one in a later post.

All the best to you and yours.
Gary Shannon

This post sponsored by
Hands-On Chiropractic and Massage
13033 SE Rusk Rd, Milwaukie OR 97222
503-656-8098 www.weadjustlives.com

Reduced Procedure ... Reduced Fees

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The Double Fee Schedule

Cash Discounts... How to do them how to bill them


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CPT Modifier -52 means Reduced Services. NOT reduced price


If you deliver a significantly reduced procedure, you MUST bill it with -52.
If you deliver a complete and full procedure as described in CPT, you MUST NOT use -52

It is the doctor's duty (not an insurance company's) to formulate a balanced fee schedule, If it's ethically appropriate to reduce fees for reduced procedures, you certainly may do so.

There is confusion that some think -52 means "reduced fee" instead of "reduced service" and use it when applying a payment discount for full services, which is completely incorrect. It's not that you can't reduce fee when using -52 ... you certainly can... it's that you don't use -52 when simply reducing fees.


There is, to complicate matters, a warning in CCI edits about fewer than 7 minutes of time code service being unbillable. It might be combined into other services, but that is more complex... thus this article in the works.

Basic Registrar Job

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Like a college Registrar, she answers the key question: How much will this cost me?

Reception has a hard time as Registrar...
Privacy and concentration needed for verifying insurance
Privacy needed to discuss care and payment plans.
The one thing the Receptionist does NOT have is privacy.

The doctor can often do it. Accounts manager or clerk can often do it.
Do it quietly and in private. This is the closest thing to a sales pitch we do.

Data Registrar MUST gather

...in general
a private place to meet
Office forms and policies
Acceptable payment guidelines


....with receptionists help
proof of identity
medical history
insurance contact
Verify insurance

....with doctor's help
today's fees
treatment plan
future fees

Forms you MUST address with patient:

HIPAA

release of records TO your office.

Permission to share information with their insurance

Insurance Verified

Payment plan summary and promise to pay.

Agreement to treatment (informed consent)

Type specific documents: WC827, PIPA, referral, pre-authorisation.

The first payment.


Last pass the data off to accounts to enter into the billing system as part of the day's traffic.
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All the best to you and yours.

Account Audit Procedure

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Below is a very complete audit procedure. You don't always have to do every step, but if the step you are on is just not making sense, go back and fill in the missing steps brings clarity. In my consulting work, this is mostly what I do.

Claim Audit

How to audit summary:

• 4 preliminary steps: Which account, posting & filing backlogs, ledger clean.
  
• 4 checks: service delivered, patient co-paid, claim sent, insurance replied
• 4 results: Paid Fair, Paid Poorly, No Payment, No Answer
• 4 actions: Patient collect, re-bill, write-off, defer

Four answers only every charge on the ledger

They paid a fair amount =
Correct coding, correct claim reading, fair benefits, correct identification.
To Do: bill patient co-pay and/or write off the balance.

They paid a poor amount. =
Incorrect coding, payer misread the claim, token benefits
To Do: Analyze and correct the reason for poor payment.

Paying nothing =
Incorrect identification, insufficient proof of service, no insurance or exhausted benefits or deductible
To Do:

No EOB:
wrong insurance, lost, not billed, or too recent for payment.
To Do: call to verify coverage and billing address and claim status, send or re-send the bill, or defer action.

Insurance Review Procedure

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com

Accounts Receivable Aging

An aging report is a list of customers' accounts receivable amounts by age. The report is usually divided into columns of 30-day increments such as 0-30, 31-60, 61-90, 91-120, and 120+. It alerts management to any slow paying accounts. AR the main tool a collector uses to identify what accounts need attention and action.

Here is a sample AR report from a printer. (instead of patients, they have suppliers) It shows the key data: who owes money, how much, and when is it due. Some are simpler, some are more complex. If your computer system doesn't produce Aging Reports for you, first call your billing software tech support. AR is such a basic tool that every account management software system should have a useful one.

One warning about AR, though...

If charges, billing, payment and write-off posting are backlogged,
your Accounts Receivable and Aging will be false.
Handle your posting first.

If your patient and account filing is backlogged,
your charts and EOB's will be unlocatable.
Handle your filing first.

Now you can print and handle your AR report.

There are four main types of insurance: Group, Auto Injury, Workers' Comp, and Government. You don't have to do all of them at once every month. For example, in one office, each Tuesday I look at the AR for one type of insurance account, and rotate through the four types each month. In large or specialty practices, one type might represent most of your accounts, and take weeks to go through at first. Some types take only a few minutes to review, so double them up. Adjust your schedule and staffing to accommodate the needs of your practice.

On the day you regularly schedule to address your overdue accounts, catch up on your posting and filing, then print out the "AR by insurance type" for the types you need to review today. Printing this on reused paper is fine, since no one is going to look at it but us.

In Oregon, Insurance companies have 60 days to pay or deny a claim. Add in a little time to write up the charts, post the charges, send the claim, and get the reply, it is realistically about 75 to 90 days (11 to 13 weeks, three months) before you can even consider insurance money "overdue." The more recent stuff, you can work on it, but there's going to be a lot of "yes, we have it... we're still processing it" results that will waste your time. Adjust your schedule if your state rules are different: some states allow only a 30 days processing time. But in Oregon,

Any insurance 90+ days owing needs action.

Quick, highlight every account with 90+ days owing claims on it. Those are the ones to address.

Claim Review

Review is a short action, taking no more than 6 minutes with an account.

1) Scan the overdue account to locate the exact charges that are overdue

• a) Look at the individual account ledger.
• b) Unpaid charges are marked different ways in different software... learn yours.
• c) Find the oldest unpaid amounts and come forward in your work.
• d) Those old unpaid charges should about equal the amount overdue.

2) Each overdue charge gets a separate handling: Open the account file to see the EOBs.

• a) if it's not billed, or if you have no EOB, bill it again, or
• b) if nothing is paid at all, call to verify insurance.
  
• c) if you already re-billed, and it's overdue, no reply again, call to verify insurance.
• d) if have an EOB in reply, read the EOB, and decide what to do

3) Decide what to do and do it. The action is usually one of these:

• a) write off what you must and bill the patient what's fair now.
• b) send a corrected claim with additional data, notes, or authorizations
• c) contact the insurance to clarify their reply, then act.
• d) flag the account for a more complex handling. (this is really rather rare)

4) Write what you did so you won't needlessly repeat what you did next month.

• a) keep your notes in the patient account file.. they will help you later
• b) find where you can keep account notes in the computer billing system... and use it.
• c) Mark off your AR list that you handled this account.
• d) Use a tickler file entry for any follow up you need to do soon.
  
• e) Put away the patient file.
  

As soon as you are done with one claim review, go to the next claim on the aging list and handle it until you get to the end, and the project is done til next month. Sometimes, though, the account is too complex to sort out with a short review. Those need an Account Audit... in another article here.

If your aging list is very long and needs lots of attention - more than you can give it today or this week - target the largest accounts first and handle them. Then go for smaller accounts next time. Or target by insurance company names in order (A-M this time, N-Z next time), or by patient names. Whatever works for you.

In a few months, this job will become smaller, since you will have most claims running smoothly, with notes in the paper files, computer files and tickler file. But you will always need to do this one last step:

Schedule when to go back to this job next month.

All the best to you and yours, Gary

This post sponsored by
Common Ground Chiropractic Center.
2927 NE Everett Street, Portland, OR 97232.
503-232-4099 commongroundpdx.com