The New Language of Healthcare


In just under a year we are scheduled to Implement ICD-10 for all HIPAA covered transactions.  This is a significant change in how healthcare business is conducted – but it is not an insurmountable change.  With a bit of forethought, planning and education we can make the transition to ICD-10 less painful.  In the coming months you’ll find tips and tasks to keep you focused on the transition.  After all, you can only eat an elephant one bite at a time!


Learning a New Language


On October 1, 2015 the language of healthcare is changing.  This new “language” allows providers, payers and others to get a better picture of the patient and far more detail regarding the reason(s) for their visit.


Learning a new language takes time.  Communication between doctor and patient isn’t impacted by the change.  You’ll still take care of your patients with the same processes, procedures and care that you do today.  The change comes in communicating with third-party payors.  ICD-10 allows providers to paint a more thorough picture of the patient, allowing the insurance companies to “see” things that they can’t with ICD-9.  This change in communication impacts the inside of healthcare; insurance companies, software vendors, hospitals and doctors.  These new codes provide a more accurate description of the conditions encountered. 


Over the next 11 months we’ll work to keep the information we provide simple, clear and useful.  We’ll work to walk you thru how to prepare for the transition, how to speak this new language and how to find the information you need to keep your practice strong.


Your task this month is to purchase an ICD-10 book and read the introduction.  It’s important that you have access to this information.  We’ll explore the transition together over the coming months.

Increasing Audit Activity by Medicare

Recently Railroad Medicare conducted a widespread review of chiropractic services.  The results of this review were disheartening.  For the third quarter of FY 2014, Additional Documentation Requests (ADRs) were mailed for just over 14,000 services.  Chiropractic was found to have a 79.5% error rate.

Out of the 14,000 services requested – 5300 services were denied without a review of the documentation.  Doctors failed to provide any documentation for 36% of the services reviewed!  Failing to provide documentation results in an automatic denial - how many providers have a 100% fail rate just from lack of submitting records?!?!

For the records reviewed, the top three reasons for denial were:

  • Required elements of the history and examination were absent
  • The Treatment plan absent or insufficient. Treatment plans most commonly lacked specific goals with objective measures to evaluate treatment effectiveness. 
  • Missing or incomplete P.A.R.T. exam to document subluxation. 

Where does that lead?  “Railroad Medicare isn’t a big payer in my practice” – is what I hear most often from providers.   If they aren’t a major payer, why bother?  

Railroad Medicare shares its results with Mamma Medicare.  

That’s right.  That not-a-major-payer just shared your profile with “big” Medicare.

Doctors who fail to provide records automatically fail the audit.  Doctors with missing exam elements, missing treatment plans, missing PART documentation – doctors who fail to implement outcomes assessments to measure progress – don’t be surprised if Mamma Medicare sends you a note - a let’s-get-acquainted invitation in the form of a Comprehensive Error-Rate Testing (CERT) request.

Cornerstone has been contacted by doctors that are now receiving CERT review letters.  The CERT review letters are requesting documentation for specific patients and specific timeframes.  This could spell trouble for some providers.

This review evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.  Their aim is to recover payments made improperly.  Last year, FY2013 Medicare recovered $36 billion dollars in improper payments. 

The error rate from this sample can be extrapolated across your patient base and applied to monies paid by Medicare for services rendered.  Imagine a request from Medicare for a refund of 79.5% of payments made?  If the results of a CERT review is similar to the results of the RR Medicare review  – ouch!  

Wonder where you are on the scale?  What would your error rate be if Medicare looked at your records?

We can help!  

Whether you are looking for a full compliance plan - or just a chart audit, contact our office for more information.


ABN forms and Medicare Advantage Plans

Many Medicare Advantage (Part C) plans had developed their own ABN-like forms to assist members in identifying non-covered service.  These forms were required by the Advantage plans if a provider intended to collect from the patient for these non-covered services.

Medicare's ABN rules clearly state that the ABN form cannot be used under Medicare Part C. Medicare put these plans on notice – the rules for Part C are different than Part B – and the ABN form is not to be used.

United Healthcare has issued the following statement:  Effective Dec. 1, 2014, the Protocol to follow to bill a Medicare Advantage member for non-covered services is:

  • Member Consent: Although you can no longer use the ANN Form referenced in the Protocol, you must continue to obtain the Medicare Advantage member’s written consent to seek and collect payment from the member for non-covered services, prior to rendering the non-covered service.
  • Pre-Service Organization Determination: If you know or have reason to know that a service that you are providing or referring for is not covered, you must request a pre-service organization determination for the service from UnitedHealthcare in order to bill the member for that service. UnitedHealthcare must issue a determination before you render or refer for the non-covered service. Please note that a pre-service organization determination is not required to bill a member where the member’s Evidence of Coverage (EOC) or other related materials are clear that a service is never covered.  

Please check out for further details.

Other Medicare Advantage Plans may have similar announcements.