Speaker 1: (00:00)
Welcome to the simplified integration podcast. My name is dr. Andrew Wells. This is episode number 26, compliance, and audits. Woohoo!
Speaker 2: (00:12)
Leonardo de Vinci once said that simplicity is the ultimate sophistication. And I agree you see the problem with the way that most consulting groups approach medical integration is anything but simple. In fact, it's the exact opposite. It's expensive, it's complicated. And quite frankly, it's exhausting enough is enough. There are far too many amazing integrated clinics that are struggling well. I'm on a mission to change that what I've come to find from over five years, working with integrative practices is that simplicity really is the secret. The old saying of less is more, is true through a streamlined approach. I was able to create multiple successful seven figure integrated clinics. And now I'm going to show you how you can do the same. Join me as I share with you the secrets to successful medical integration and practice growth. Join me on a journey to greater sophistication through innovation. I'm dr. Andrew Wells and welcome to the simplified integration podcast.
Speaker 1: (01:10)
Hey, what's happening, doc. Great to have you back. So today we're gonna talk about a really exciting topic, compliance and audits. Uh, I hope you can detect my sarcasm. Uh, this is actually a really scary topic for a lot of doctors. And I know when I first integrated years ago, one of my biggest concerns was, uh, are we going to be in compliance? Are we going to be able to follow the rules properly? And medical integration seemed like a really complicated thing when it came to compliance and making sure we're following HIPAA and OIG regulations. And I wanted to, to make this podcast to give you a couple of tips and also some things to be aware of and maybe some things to make sure that you're doing properly. So here's the deal. I am not a compliance officer. I'm not a healthcare attorney. I am a consultant.
Speaker 1: (01:53)
So what I'm telling you is I'm not an expert in this area, but that doesn't mean that I can't help you in this area. And my biggest suggestion is there are a lot of resources and people that you can use. And third party companies and attorneys, you can hire to make sure that you're doing all of the, all of these things correctly. The medical playing field is extremely complicated. There's a lot of rules. There's a lot of regulations. There's a lot of red tape. So if you're thinking about integrating, I really encourage you to take what I'm saying to really seriously. And if you're already integrated and you you're listening to this podcast, my hope is that you'll take some of this information and resources. I'm going to give you today and implement these in your practice as soon as possible. Now, um, the, the thing about compliance is you, you don't know what you don't know what you don't know, and this is why when we run practices and open offices, we always bring on a compliance team to make sure that they're looking over our shoulder to make sure that we're doing things properly.
Speaker 1: (02:49)
So I want to read off of a list of things that I'm, that chiropractic integrated offices, medical, integrated offices are, um, getting some scrutiny over and getting in trouble for. So I want to make sure that these are not things that you're having issues with or don't have issues within the future. So number one, making sure that you're, you're keeping, um, you're keeping up corporate record keeping. So every year, and this may depend on what state you live in, but you need to, uh, keep track of corporate meetings. You have to have an annual meeting, you have to, um, uh, document that you had this meeting and make sure that all the members of your entity, um, are, are a part of this meeting. Um, if you're not sure how to, how to do a corporate meeting or keep these records, there's all kinds of resources, resources online that you can use.
Speaker 1: (03:34)
Um, and I'll give you some resources at the end. Uh, issue. Number two is, um, billing for things that are not medically necessary. Now you probably already realize this, but as a chiropractor, you, you can't, uh, diagnose people or make recommendations for people for medical issues. So in other words, let's say, um, you think that a patient needs a knee brace or a back brace. Well, as a chiropractor, if you're going to build that under their medical insurance or Medicare, you ha you can't be the one making the diagnosis and making recommendations. So instead you have to have a medical practitioner doing that. So that could be a nurse practitioner or physician assistant medical doctor DEO, uh, any medical provider. And also you need to make sure that you document that it was medically necessary for the patient. And how do you do that? So you, obviously, you need to do an exam for, if you're doing using it for orthopedic purposes, you may want to have an X Ray to back up your claim of medical necessity.
Speaker 1: (04:32)
And you also need your provider to fill out a form that says I'm prescribing this brace or this service for the patient, because we deem it medically necessary. And the key here is that if you don't, if it's not documented, it didn't happen. So we're doctors get in trouble, is it, let's say you get an audit. And Medicare says, Hey, who, uh, who authorized all these, uh, knee braces that you build? And the nurse practitioner who's already long gone or on a different job said, Nope, I didn't do that. I didn't recommend those. And so if you don't have this documented on a piece of paper, then it never happened. And then it makes you as a clinic director of the chiropractor look really bad and it can set you up for all kinds of legal and compliance issues. Um, so you need to make sure that you're documenting medical necessity from your medical provider, billing and coding.
Speaker 1: (05:16)
This is one where a lot of ducks get in trouble. So there's two things you can do here to make sure that you're, um, that you're setting yourself up for success. Number one is make sure that you're hiring a certified medical biller and coder. There are a finite, uh, number of codes that you can bill for, and you want to make sure that you're applying the right bill for the right therapy that you're providing the patient. And I wouldn't, um, you know, this is a, uh, uh, certified, like you have to have a degree in a certification to become a certified medical biller and coder, not a degree, but you have to have a certification because it's complicated. So instead, my recommendation is instead of having like one of your front desk staff members or someone in your office, uh, try to learn medical billing and coding and compliance, hire that out to a third party company.
Speaker 1: (06:02)
Who's trained and certified in that because they know and should know how to build properly. However, I wouldn't just trust a certified biller and coder just because they have that certification. So the second layer of protection is you always want to have someone looking over your shoulder to make sure that the biller is billing appropriately. So the way you can do that is you can hire a healthcare attorney. You can hire a compliance auditor, and there are all kinds of third party compliance organizations that will do what they call a baseline audit. And what a baseline audit is, is a team will come into your office or do it virtually they'll look at your patient files and your diagnosis codes and your therapy codes. And they'll match that up to what codes you're billing for and to look for any kind of irregularities. So this is a great, they'll give you a roadmap on what you're doing well, what they suggest you change, and maybe what some of the red flags are.
Speaker 1: (06:53)
Um, and this is really important because, and it's important to do early on in your practice, because if you're making mistakes, you need to correct those mistakes. If you're, if you keep making the mistakes over and over again, um, and you can't just claim, Oh, I just, uh, I was ignorant, right? So if Medicare comes in or blue cross blue shield comes and they do an audit and they find out that you've been billing and properly for years, um, not only do you have to pay all that money back, but there's also all kinds of fines and penalties and potential criminal exposure to you and your office. So this is like, um, this is a biggie here is I don't overlook and always have someone checking, uh, whether or not you're billing properly. Um, so let's, uh, Oh, and then I also want to talk about, um, when it comes to, I talk a lot about regenerative medicine and there's been a lot of chatter about, um, using certain Q codes, billing, Medicare and insurance Q codes for regenerative medicine, and I'm there.
Speaker 3: (07:49)
Speaker 1: (07:49)
Most of the codes that are available for regenerative medicine are for wound care. So wound care being, uh, for people who have, um, diabetic ulcers or burn victims, those kinds of patients, and it's not approved for orthopedic purposes. So like for the same reason you would use hyaluronic acid or Supartz, or Jenn Vickery, all these other products for osteoarthritis in the knee, um, you can't use those same procedure codes for regenerative medicine as of yet, uh, some management companies and groups will tell you, you can do that. So if you want to follow their advice, I would just urge you to make sure that you're vetting these codes through a healthcare attorney and get a healthcare attorney's opinion first, before you start using those codes. So here's the deal about consultants and management groups. I'm a consultant don't trust consultants when it comes to billing.
Speaker 1: (08:37)
All right. So just because someone said, Oh yeah, you can make a ton of money building this code, great. Vet it through a healthcare attorney to make sure that it's legal and compliant. So don't take my word for it. Don't take some other consultant or management group's word for it, always vet these codes through, uh, through a compliance organization or attorney to make sure that they're not just blowing smoke. And by the way, I know a lot of chiropractors and consults consultants, they blow a lot of smoke and they get a ton of doctors in trouble. Uh, they make their money up front and then you get screwed in the end. So just don't be a victim to that. And that's happened to me by the way before. So, uh, that's why I get pretty irritated when I, when I talk about it. Alright, so number four, um, self-referral restriction.
Speaker 1: (09:20)
So this is, this is key. If you're doing things like, uh, DME rehab, physical therapy in your office, you want to make sure that, uh, you're not getting in trouble with, uh, stark law and stark regulations. And this is a, this comes into play when you're receiving compensation for referrals. So if you're a chiropractor referring patients to a medical office or a medical office, or Frank patients to a chiropractic office, you need to make sure that the way you're referring patients and the way you get compensated for those patients is compliant in your state. Each state has different laws and regulations, and you also have the federal laws and regulations. So this is another area where you want to make sure, um, it's a great thing to do a baseline audit to make sure that these referral relationships don't violate any stark rules. And then we have a supervision and scope of practice.
Speaker 1: (10:08)
So with, with this, um, this subject where a lot of doctors get hung up on and get in trouble with is not billing properly under the provider that provided the care. So here's where this comes in play. Let's say you're doing physical therapy and you have a physical therapy assistant in your office. If the physical therapist isn't present and actually doing the work in your office in most States, you can't bill under their license. You have to bill under a PTA license. And so the, and this is another thing that you want to make sure you have an attorney or a compliance organization look at to make sure that you're, um, you're not billing improperly for what's called incident two billing. So in most cases you have to bill under the provider that actually provided the hands on service with the patient. I know a lot of chiropractors that I've gotten in trouble with billing under the provider, that wasn't actually in the office and making those mistakes.
Speaker 1: (10:57)
So make sure that you're paying attention to that and you know, the rules and regulations in your state. Um, so we also have a, this is, this happens a lot I know in chiropractic offices, but it's really important that you're not, um, waiving deductibles and patients copay. So it's, this is a, this is a law. So if a patient comes in and they have a $30 copay, you have to make sure that you charge the patient that $30 copay. You can't just wave it. Even if they have a financial hardship, like if they're, they just lost their job or they don't, they have a really fixed income. Um, just because you want to help the patient got a pain or help them from a clinical standpoint. And you have a big heart. That doesn't mean that you can't just avoid collecting a copay that's against the law.
Speaker 1: (11:40)
In most cases. Now there are some instances where you can do a financial hardship, but you have to document for that and make sure that it's truly a financial hardship. Um, so I want to talk about, so we talked a little bit about insurance based cash based services are not immune. I've heard this from quite a few chiropractors and they say, Oh, I don't have to worry about compliance. I don't bill Medicare. I don't build third party insurance. I just do cash. Well, that's great. But you also need to make sure that your fault there's, there's compliance also for cash based services, not just for HIPAA compliance, but also there's a lot of ducks get in trouble for, um, false advertising or deceptive marketing practices, or they get in trouble for the type of marketing they're doing in their state. So those are just because you run a cash practice does not mean you don't have to pay attention to compliance and state and federal federal regulations.
Speaker 1: (12:32)
Uh, and then lastly, so this is coming down the pike here later this year in 2020, the FDA is going to be cracking down on offices and labs that produce regenerative medicine and STEM cell products to make sure that they're following the regulations under, under section three 61 of health services, the health services act. So there are a where this applies to you is that if you're using like, um, a STEM cell based product, the lab that you get your products from has to be following FDA guidelines. If they're not, they're going to get wiped off the face of the earth. And it also could expose you to potential liability. If you're using a product has not been approved under section three 61. So this is really easy to, to verify, um, the lab that you get yourselves from can provide you with a certificate that says they have this, um, the certification of this documentation, they, that they follow those guidelines.
Speaker 1: (13:27)
Um, so a couple of things you can do here. So those are all the things I wanna address. Those are some of the common issues that are affecting chiropractic medical, integrated offices, or MD DC offices. So here's the deal. Uh, if you, there, there's two ways you can go about this two general ways. Number one is you can hire a healthcare attorney to do a baseline audit and healthcare attorneys will go through your office and go through your files, your private pay insurance, Medicare insurance, and they'll make sure that you're following a guidelines appropriately. And it also gives you recommendations on things to change, to tighten up your compliance. So if you need some recommendations on who you can use for that, um, email firstname.lastname@example.org. And I can provide you with some resources on that. Also, there are third party compliance organizations that do, um, uh, not just one attorney or a couple of attorneys working together, but they do a HIPAA compliance.
Speaker 1: (14:18)
They do OIG compliance, they do billing compliance. And so they can potentially help you in other ways that, uh, uh, that your office may need help. So again, you don't know what you don't know what you don't know. So we always hire these professionals to look at our office and look over our shoulder, to make sure that we're doing things properly. It's going to cost you some money. And that's where doctor is like, ah, I don't want to spend a thousand bucks or 5,000 bucks doing this, but if you don't do it up front and you're not having someone check your compliance, you're going to pay it down the road in fines and penalties. And I can promise you one thing, it's going to be exponentially more expensive to pay it after the fact, back to the government or back to private insurance, because you made mistakes that you weren't aware of.
Speaker 1: (15:02)
So, uh, to doctors who are concerned, and I talked, I speak to doctors who are concerned about, um, getting into medical integration because of the compliance issue or potential compliance issues. And here's what I'll tell you is that there are tens of thousands of medical offices every day that are billing for medical services. And there's no reason why you can't run an MDC, prep, practice, and bill for insurance based therapies or cash based therapies. But most medical offices, I know have a compliance team and they have attorneys and a third party companies that are making sure they're doing it appropriately. So if you're going to get into the medical realm, hire this out to somebody, I would hire them out. At least in the first six months, you know, preferably day one, the day you start seeing patients as a day, you should start, um, with a, with an auditor, a baseline, a baseline check on your practice, but there is a way to do it appropriately.
Speaker 1: (15:55)
There's a way to do it the wrong way. So if you want to be able to sleep at night and you don't have to, you don't have to worry about when your next audit is going to come up and how that's going to go. Um, do your due diligence and invest in your office, investing compliance, because not only will it save you money in the long run, but it'll help, uh, keep you away from a liability and potential exposure to things like fraud and criminal issues and all the clawbacks that I'm sure you've heard of in the integration business. So, uh, that is my 2 cents. Again, I am not a compliance officer. I'm not an attorney. I don't do that stuff. But what I'll tell you is that I think you should hire that out to a third party company, make sure you're safe. Uh, I hope you found this, uh, topic valuable. Um, and I hope this surgery clinic well, and look forward to seeing you on the next podcast episode. Great to have you on here at doc and we'll talk to you soon. Bye bye.
Speaker 2: (16:46)
Hey innovators. Thanks for listening to the simplified integration podcast fact that you're listening tells me that you're like me, someone who loves simplicity and the truth is those who embrace simplicity are some of the greatest innovators. So hope you got a ton of value from what we covered on today's episode. Be sure to subscribe and share with other docs that you feel could benefit from greater sophistication through simplification and innovation. If you've got specific questions that you'd like answered on this podcast, or you've got specific topics that you'd like me to discuss, just shoot me an email at email@example.com that's firstname.lastname@example.org.