Appropriate Billing Practices
Editor's note: The following letter to the editor is directed to DC columnist Samuel Collins in response to his Nov. 5, 2007 article, "Discounting Services for Certain Patients."
Dear Mr.
As a chiropractic physician entering my 29th year of practice, I have served on many state peer-review and insurance fraud committees. I read with great amusement your cash-discounting article in the Nov. 5, 2007 issue of Dynamic Chiropractic.
The fictitious question regarding the use of modifier 52 to reflect a cash discount on an insurance bill is preposterous. First, there would be no insurance billing submitted for a cash patient; and second, this is an inappropriate use of modifier 52, as a reduction in record-keeping does not constitute the reduction in the medical service rendered, which is the intent of modifier 52! Submitting a claim for a service rendered at other-than-standard fees would constitute two-tier billing fraud.
If, hypothetically, a cash patient somehow needed a bill for insurance purposes, the correct way to do so would be to show the standard fee charged with the lesser amount paid by the patient and a zero balance due. This now legitimately indicates to third-party payors and the local governing agencies that a financial adjustment was made for this indi-vidual's account, and is noted in the medical record, should they wish to review the reason for the discount. By the way, in almost every state, the patient must present and the doctor must document a financial hardship as the reason for discounting services.
Paying cash is not a generally acceptable reason, and if the doctor is caught, it will result in that cash price now being the usual and customary fee for that practice; and every third-party claim previously submitted will be adjusted to that cash price! The only acceptable discount for cash is if an entire treatment plan (e.g., a spinal decompression series) has been pre-paid in advance. Then a cash bookkeeper's discount may legally be applied, but keep in mind that any pre-paid monies must be kept in a trust fund and only withdrawn as each service is rendered. The billing statement for this scenario would be prepared using the aforementioned method.
F.W. Storer, DC
Tequesta, Florida
Time to Rethink California's 24-Visit Cap
Editor's note: The following corres-pondence was originally sent to the First District Court of Appeal in San Francisco, which is being petitioned to reconsider California's 24-visit cap on industrial injuries. It is paraphrased as follows.
I am writing to urge you to reconsider the injustice of the 2004 legislative determination that a definite "24-office-visit limit" is reasonable for the care of injured workers. Having practiced chiropractic for 30 years, I am certain that there is no justifiable or scientific basis for the number "24". Degree of injury varies widely. While many patients need far fewer than 24 visits, many need more than that.
The absurdity becomes immediately apparent when the insurance industry lumps together a patient with "chronic needs" with permanently disabling injuries, with say, another worker who has had a temporary and passing lower back episode. The industry's sham solution is to "average" their needs, satisfying neither injured worker. Those who come up with such ill-conceived resolutions would agree to the following scenario:
Four workers are occupants in an automobile. At full stop, their car is struck at 50 miles per hour. Chances are, there may be four different outcomes. One occupant is knocked unconscious. One has a broken neck. One is dead on impact, and the other, only feeling "shaken," goes to the aid of the other three. What would the claims adjustor recommend in this scenario? Using their formula, as ridiculous as it sounds, each would be entitled to 24 office visits, because on "average," that would be their need. Ê
When I write my worker's compensation reports, as a treating physician I am required to place the following italicized, excerpted LC 139.3 "admonition" at the end of my report: "I have not violated labor code section 139.3 and the contents of this report and bill are true to the best of my knowledge. This statement is made under penalty of perjury. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purposes of obtaining or denying worker's compensation benefits or payments is guilty of a felony."
Blindly suggesting that 24 visits is reasonable for every case approaches fraud.
Donald Kerry Wilson, DC
Davis, California
The Subluxation Will Always Be With Us
Dear Editor:
It's time to move beyond David Seaman! Why not just do away with the entire foundation of chiropractic and build our respective houses on the sand? We wonder why the MDs are always snickering behind our backs - one of the reasons is that the profession doesn't know what it believes or why from one minute to the next. Modalities come and go, coaches come and go, but the subluxation, like it or not Dr. Seaman, will always be with us. If you do not know how to correct it, perhaps I can show you.
As far as his "first measure" stating that we need to give up the notion that adjustments have magical or supernatural healing outcomes - just ask most chiropractors why they are chiropractors. It is usually a "miracle" story about how they or a family member was healed by chiropractic, which lit the flame within to want to help others. But hey, forget all that and jump on the bandwagon of reality instead of having the dream to change people's lives.
It is that dream that keeps us going in the midst of everyday life at the office; the knowledge that occasionally, unexpectedly, we come upon that case no one else is able to help. Seeing the tears of joy on the patient's face when for the first time in years they are able to do something they could not do before. There are moments in this profession when, believe it or not, money is not the object - restoring health is. And the first and best way to do that is by finding and correcting the subluxation.
Philip M. Lawrence, DC
Submitted via e-mail