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​Don constantly writes articles for magazines & articles for newsletters on ERISA, Medicare, billing coding, PQRS, HIPAA & more. If you're looking for articles on Medicare, you may want to check out his newsletters or even attend some of his webinars on Medicare & these other subjects on our WEB SHOP.   Fraud & Abuse is a problem with Medicare & other payers & our goal is to help educate physicians on Fraud & Abuse, & how physicians can stay compliant with the Fraud & Abuse laws with Medicare & other payers.  Please enjoy these articles & if you have any questions, please let us know.  It is better to stay compliant & stay within Medicare regulations than it is to find out AFTER you've violated them!  I'm sure you do not want to be wearing an orange jumpsuit and picking up trash on the side of the highway because you didn't know what the rules say.

This supplement to my Feb 2009 monthly newsletter covers Medicare's requirement that the person hooking up the electrical stim or any other PT service is required to complete a PT curriculum as well as the billing codes - in pdf.   It also reiterates Medicare's viewpoint that only ONE CODE can be used for each 15 minutes, in spite of what your equipment salesperson is telling you.

CMS does not require doctors use E-Codes for external causes of injury yet.   They do not require it for ICD9 and probably will not require it for ICD-10 at first either.   Many workers compensation carriers and state workers comp boards want you using E-Codes.  You’ll have to check with individual commercial carriers to see what they want.

"Incident to a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness." (Medicare IOM Publication 100-02, Chapter 15, Section 60.1).CMS defines incident-to services as those that are "furnished incident to physician professional services in the physician's office (whether located within a different office suite or within an organization) or in the patient's home. (NOT hospital or nursing home)CMS states there are two ways in which a provider /practice can bill for services rendered by an NPP, they are as follows:
•    Under the NPP's identification number
•    "Incident-to" the physicians care and billed under the physician's provider number

What Criteria must be met for Incident-To Billing?If a practice chooses the second method of billing services, hence, Incident-To a physician's service, the following criteria must be met to stay compliant with CMS guidelines:
•    A physician must initially see the patient and establish a plan of care.
•    The services rendered by your NPP are typically offered in the office and are part of a documented treatment plan.
•    The physician is on-site, contiguous - not necessarily in the same room, but in the same office
•    When the mid-level sees the patient so that the physician is readily available to provide assistance if necessary
•    The physician must continue to be actively involved in the patient's plan of care.

As you probably already know, I have read the entire PPACA and have tried my best to keep up with all of the changes to it, which has been surprisingly difficult since this “law” has been changed by the President numerous times without being sent back to Congress for changes (as the constitution calls for, but that’s a different subject). You may or may agree with what my conclusions about the law, but that’s ok as everyone has a right to have their own opinion, but I’m going to share it with you anyway. After thoroughly studying the original UCA (Unaffordable Care Act) and all of the changes to it to make it “appear” that they are trying to make it work, I do not believe that was it’s purpose at all.  

​To get to be the president of a nation and to get to be in the position that (most of) his advisors are in, you have to be smart.  That doesn’t mean you have to have any common sense or have any ethics or even have any morality, but you do have to have intellect to some degree. I am firmly convinced that there is no one with that level of required intellect that could truly believe that a system could work that would expect younger, healthier people that were currently without health insurance coverage to spend hundreds of dollars a month on an insurance policy that would not take effect until they had spent at least $6,000 in a year, rather than pay a $95 a year tax.

​Knowing this, the same person with intellect would have to be smart enough to know that a system that would require at least 7 Million people to enroll in it or it would fail, would not give a $95 a year option, knowing that a good number of Americans would choose that option.  The same person would know that failure to enroll the younger, healthier people would cause the insurance policy premiums for the older people to triple over the already high ($600 to $1300 per month) quotes they were given causing them to drop their policies upon notice that the premiums were tripling.  When you combine the fact that they spent $640 Million on a website that failed from the beginning and continued to fail and did not provide even one mechanism for the policy payments to be paid to the insurance carriers, it’s ludicrous to assume it would work. 

All of this leads me to the unescapable conclusion that the entire PPACA (Obamacare, UCA or whatever you want to call it) was designed to FAIL.   

Failure can only lead to one thing and that is a single payer, government run system. Had a single payer, government run system been presented to or offered to the American public, there is no way it would have been accepted - but as a result of a failed PPACA system, it will be the only alternative.

My advice is to start working smarter, increase your practice income now and set aside some money in the bank as I honestly have no idea what the future holds.  God does - but I don’t.  Fortunately, I trust Him though, as He is in control.  Not me.

This past week, I was in a primary care office that is owned by the hospital.  The physician told me that since he “sold” his practice to the hospital, they have been driving off many of his cash patients because the amount the hospital was dictating be charged to cash paying patients  The doctor expressed that it was hurting the practice (this doctor’s income is based on salary plus percentage of practice profits).   I explained to him that it was probably someone at the hospital that had no idea how to run a physician practice (very very few hospitals have any idea how to run a primary care practice) and probably believed that you have to charge everyone the same - WHICH IS NOT TRUE.   

​It is kinda shocking to me how many people believe that there is some law out there that says you have to charge everyone the same fee, even though not one of them can find, quote or reference the non existent law.    There are many that believe that Medicare says you can never charge anyone less than what you charge Medicare - and that law or regulation doesn’t exist either.

​Unless your practice is owned by a hospital that is clueless, you can set your fees at different levels for insurance and cash patients if you wish to.  Even Texas - that has a law saying you must charge all payers the same - doesn’t say anything about cash patients - as they are not considered “payers”.

The Food Stamp Program, administered by the U.S. Department of Agriculture, is proud to be distributing, this year, the greatest amount of free meals and food stamps ever, to 46 million people. 
Meanwhile, the National Park Service, administered by the U.S. Department of the Interior, asks us "Please Do Not Feed the Animals." 
Their stated reason for the policy is because "The animals will grow dependent on handouts and will not learn to take care of themselves." 



A client in Florida earlier this year bought a couple of pieces of equipment from someone after I had warned the doctor that I did not trust the saleslady, or the codes that were given to him or the equipment itself.   He did not listen and he spent more than $200,000 on several pieces of equipment.    After it was delivered and the checks cashed by the salesperson, the doctor’s staff contacted me again to verify the ability to bill for them.  I pointed out the obvious in the Medicare LCDs, and told the doctor that he had a very expensive boat anchor.  Just today, I heard from another well respected consultant who was helping a doctor that had a $220,000 demand from a major carrier for the doctor billing for that exact equipment.  Doctors - before you buy anything - even if you trust the person - check with me.  My job is to keep you out of having to wear an orange jumpsuit while picking up trash on the side of the highway.   I’ve been doing it for 28 years and none of my clients are singing the Folsom Prison blues.