One statement says it all: Health care fraud is now the number three law enforcement priority in this nation just behind terrorism and violent crime. In every area of wellness centers, learning how to deal with laws and regulations can only improve your business. In this day and age, every health care professional should have a health care attorney that understands state and local regulations as well as the federal laws governing Stark regulations and a written compliance plan.

            Additionally, there are tools such as functional outcomes software and a new in-office collections tool that can help insure compliance in the areas where most of the violations occur; documentation errors and omissions and negligent collection of co-pays and deductibles.


Stark The Basics

            The Stark regulations are a set of regulations designed to prohibit the referral of patients for medical services to an organization in which the referring physician has a financial interest. Stark regulations only apply to federally reimbursed health care programs such as Medicare and Medicaid; however, there are some individual "mini-Stark regulations" that must be addressed for all insurers in certain states. These regulations apply to all licensed health care providers.



            The Health Insurance Portability and Accountability Act covers issues associated with a patient's privacy of health care information. All health care providers should have a HIPAA Notice of Information Practices form signed by each new patient and all employees. They need to read, understand and sign your office compliance policy. Even such things as sign-in sheets for patients should now be the removable labels or other anonymous mechanisms whereby other patients cannot identify who is visiting the facility.



            One of the most common reasons that practitioners find themselves in compliance trouble is incorrect coding and case management. Whereas the correct coding should dictate the necessity for length and scope of treatment, this first step becomes a critical one. That is, for a given set of findings and complicating factors, a patient should have a certain number of treatments over a certain amount of time.

            The time and number of treatments are rather standard without the documentation of complicating factors such as previous episodes of the same condition, presence of skeletal anomalies, presence of severe pain or symptom being present for more than eight days prior to the initial visit. Other complicating factors can be such things as diabetes, obesity, diet and lifestyle factors, stress and literally any other circumstance that can impair the ability to heal and predispose to exacerbation.

            Remember the golden rule; if it isn't written down, it doesn't exist or didn't happen. That is why it is so critical to use sound documentation procedures. It is especially important when dealing with functional outcomes procedures or when building your case for "more than typical" time or treatment requests. The new Correct Coding Initiative (CCI) edits cover this subject in detail and now specify which codes are mutually exclusive and also which are comprehensive to other codes.


Co-Pays and Deductibles

            The issue of the diligent collection of co-pays and deductibles is a big one that is about to get a lot bigger. As self-insured corporations attempt to reduce their skyrocketing health care costs, one of the key mechanisms they use to achieve this is increasing co-pays and deductible amounts to put some of the responsibility back on the patient (employee). When practitioners "waive" or are "not diligent" in collecting these fees, they undermine the company plans and are squarely in violation of the law (financial hardship forms are NOT adequate here). Rest assured, self-insured companies and their assigned health insurance company are aware that these practices occur and are determined to stop this activity in short-time.


Multi-Disciplinary Means Multi-Complicated

Although I believe that a multidisciplinary practice represents the future of a successful practice, there are several legal issues that must be addressed to insure compliance. A group of supervision guidelines known as "incident-to" rules have recently changed, and practitioners who supervise anyone providing treatment services to a patient "incident-to" a visit being billed under the identification of the licensed practitioner need to be acutely aware of the rules governing such visits. Suffice it to say these rules can be a bit vague but certainly need to be spelled out specifically in your written compliance plan and strictly adhered to.

            Specific professions have their own criteria in each state that must also be adhered to in this domain as well. For example, physical therapists' supervision of PTAs and PT technicians is dictated by the state PT board, and a DC supervising a CA is governed by the state Chiropractic Board. New to these changes is a ruling that DCs cannot perform services incident to a medical visit, which dramatically changes things for those who may have been practicing in this manner. If this is the case in your practice, contact your health care attorney immediately. If you do not have a health care attorney, contact us and we will refer you to one in your state that can help point you in the right direction.

            Richard Perryman, D.C. is the founder of Opinion Leaders, a new practice and fitness consulting organization specializing in the implementation of integrated, multidisciplinary operating systems into current health care facilities and fitness clubs. Dr. Perryman is also the founder of Health Coach Corporate Wellness Centers, which has become a model for integrated, wellness-based practice. Health Coach Corporate Wellness Centers deliver Web-based health assessment and promotion programs to over 500,000 individuals in Arizona and California. It offers employee benefit programs and corporate wellness initiatives. You can contact Opinion Leaders at 800.818.7170.


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