In this Issue
- Fulcrum Health Headquarters is Moving!
- 2018 Centers of Excellence Applications – Extended until April 1st!
- Billing Members
- Non-Covered Services
- 3.11 Restrictions on Claims Against Members
- CPT 2018 Code Changes for Chest X-Rays
- PHQ-2 Assessment
- Depression Common in U.S., Women hit hardest
- Moving or Retiring? Let us Know!
We will open a new headquarters location in March 2018 where we will make our home at Plymouth Woods Office Center in Plymouth, MN. The new space will accommodate a projected 20 percent staff increase throughout 2018. We are continuing expansion of our physical medicine network across the Midwest which currently features more than 2,400 providers and is available to approximately 1.7 million eligible health plan members. As part of planned staff and sales growth, we are delighted to have hired Shireen Stone as chief operating officer (COO).
The appointment of Shireen Stone to its C-suite and the relocation to the new Plymouth headquarters supports the company’s future growth plans and network expansion efforts.
Stone brings more than 20 years of health care experience in information technology, program management, process improvement, and revenue cycle operations. She will be responsible for the day-to-day operations of Fulcrum Health, as well as maintaining relationships with network providers and partners.
Prior to joining Fulcrum, Stone held leadership roles at Park Nicollet Health Services and HealthEast Care System, and most recently with CliftonLarsonAllen LLP, providing advisory services to a national base of health system, hospital and physician practice clients.
Fulcrum is pleased to announce Fulcrum’s ChiroCare Centers of Excellence (CCoE) application process is open to the entire ChiroCare network. We encourage you to take a close look at the CCoE program overview and learn more about the application process here. The self-assessment tool will assist with determining your readiness to apply.
We are accepting applications from network providers who believe their clinics meet the Centers of Excellence criteria. The application period has been extended until April 1, 2018. If you have any questions about the ChiroCare Centers of Excellence program, please contact Dr. Vivi-Ann Fischer at 651-389-2006 or firstname.lastname@example.org.
Current CCoE clinics are not required to send in an application but will be asked to participate in a verification review in early 2018.
Providers often place their patients at ease by explaining the examinations and treatments they are performing. However, a misunderstanding regarding insurance coverage can spark frustration for you and your patient later. Take time to speak with your patients about their benefit plans and financial responsibilities—for example:
- Advise your patient of their copayment.
- Explain your office policy on missed appointments.
- Discuss the services that may not be covered by the patient’s health plan.
Covered services, exclusions, and limitations are described in the member’s benefit contract with their health plan.
Unless otherwise noted on the Plan Summary, you may collect in advance of services, and/or, bill your patients when:
- Copayment is not collected at time of service.
- Patient exceeds their yearly benefit maximum.
- Patient is not eligible or services are not covered.
- Patient misses an appointment without canceling; and the applicable state or federal law does not prohibit billing the patient.
- Benefits were not assigned to you, and you are not able to obtain the primary health plan’s Explanation of Benefits from the patient within 90 days from the date of the primary health plan’s payment.
We encourage you to communicate openly with your patient about all appropriate treatment options that are within your scope of professional licensure, regardless of benefit coverage limitations. You may feel that some services which are excluded or limited under your patient’s benefit plan are of value to your patient. If you provide such service, you may bill your patient only if the below requirements are met.
Commercial and Medicaid Members:
You must obtain written approval from your patient (or responsible guardian) prior to providing the service. It is recommended that Fulcrum’s Non-Covered Services Financial Disclosure Form be used to meet this requirement. The form and the Fulcrum Billing for Non-Covered Services policy can be found at www.chirocare.com in the Practice Forms and Tools section. If you elect to design your own form, it must comply with the requirements of this policy, with the form including:
- Provider name
- Provider address
- Detailed list of non-covered services for which the member may be billed and the cost associated with each
- Signature of the provider or health care representative who explained the Financial Disclosure Form and discussed available options to the patient
- A clearly written statement indicating the patient’s understanding that the identified services are not covered by insurance and patient agrees to pay for them in full
- Patient name
- Patient signature
- Date of patient signature (Must be obtained prior to the service being rendered and may not pre-date the billed service by more than 12 weeks)
Medicare members (including MSHO where the health plan sponsored Medicare policy is primary):
For services that are covered in some cases, e.g. spinal manipulations, a provider must obtain an authorization denial, prior to the service being rendered, in order to bill a Medicare patient. Execution of Fulcrum’s “Non–Covered Services Financial Disclosure Form,” cannot be used to support Medicare patient billing for spinal manipulations or any covered x-rays on the applicable Fulcrum Fee Schedule, even if the care is maintenance in nature. See the applicable Plan Summary for instructions regarding authorization submissions.
It is not necessary however, for providers to obtain a denial from the health plan or Fulcrum to bill Medicare members for services that are never eligible for payment when rendered by a chiropractor. Providers may collect for these services at the point of service, or via distribution of a bill. Prior to rendering the service however, Fulcrum does recommend that the provider use Fulcrum’s “Medicare Member Notice of Non-Covered Services” form to help ensure the Medicare patient’s understanding of financial liability, and to avoid potential misunderstandings and/or member complaints.
Chiropractor shall not bill or collect payment from the member, or seek to impose a lien, for the difference between the amount paid to chiropractor and chiropractor’s billed charge, or for any amounts denied or not paid under this agreement due to:
- Chiropractor’s failure to comply with the protocols
- Chiropractor’s failure to file a timely claim
- Payor’s benefit plan or plan summary
- Breach of the agreement between Fulcrum and a payor
- Nonpayment by a payor
- Inaccurate or incorrect claim processing
- Insolvency or other failure by payor to maintain its obligation to fund claims payments, if payor is Fulcrum, or is an entity required by applicable law to assure that its members not be billed in such circumstances
- A denial based on medical necessity or prior authorization. This obligation to refrain from billing members applies even in those cases in which chiropractor believes that Fulcrum or payor has made an incorrect determination. Instead, chiropractor shall follow the claim appeal procedures as further described in the Protocols.
The following seven CPT codes are no longer valid:
- 71010 Radiologic examination, chest; single view, frontal
- 71015 Radiologic examination, chest; stereo, frontal
- 71020 Radiologic examination, chest, 2 views, frontal and lateral;
- 71021 Radiologic examination, chest, 2 views, frontal and lateral; with apical lordotic procedure
- 71022 Radiologic examination, chest, 2 views, frontal and lateral; with oblique projections
- 71030 Radiologic examination, chest, complete, minimum of 4 views;
- 71035 Radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies)
These are being replaced with the following four new chest x-ray codes:
- 71045 X-ray of chest, single view
- 71046 X-ray of chest, 2 views
- 71047 X-ray of chest, 3 views
- 71048 X-ray of chest, minimum of 4 views
This month’s compliance article will focus on the importance of routine password maintenance and best practices.
With cyber-attacks on the rise, it is more important than ever to take precautionary steps to protect yourself, your employees, your business, and most importantly, your patients’ privacy. While the Health Information Privacy and Accountability Act (HIPAA) Privacy Rules do not have explicit requirements on user passwords, there are still addressable items for covered entities, like provider offices. The HIPAA password management requirements can be found in the Administrative Safeguards of the HIPAA Security Rule §164.308(a)(5).
- Procedure(s) for creating, changing and protecting passwords
- Passwords should be changed every 45-90 days
- Develop password requirements – capital and lowercase letters, number, special symbols, cannot reuse an old password, etc.
- Complete an office walkthrough to ensure that staff are not posting passwords in their work stations (under keyboards, posted near their computer or written on post-it-notes)
- Review your policies and procedures on an annual basis and distribute to staff
- Ensure staff are aware of the importance of protecting passwords
No plan is 100% fail-proof but by following these best practices, you can help lower your risk of potential cyber-attacks. Working with a security or information technology vendor can also provide you with additional administrative safeguards, as identified within the HIPAA Security Rule. However, should your office’s system be hacked, be sure to have a plan on what to do. Complete a Breach Risk Assessment to determine the scope of the incident and based upon the number of patients affected.
As always, if you know or suspect Fraud, Waste, and Abuse is occurring in your place of business, please report it immediately to Fulcrum’s compliance hotline at 1-866-714-0526. Tips can be left on this voicemail 24/7 by anyone (provider, office support staff, patients, etc.).
Providers can use the PHQ-2, two question assessment, to screen for possible depression and refer patient back to primary care for evaluation and treatment.
Nearly 1 in 10 U.S. adults has depression, and the rate is almost twice as high for women as men, health officials say.
National survey data showed that more than 8 percent of adults aged 20 and older suffer from low mood, according to a new report from the U.S. Centers for Disease Control and Prevention.
Among women, slightly more than 10 percent have depression, versus 5.5 percent of men. And the mood disorder affects everyday life for a majority of these people, the 2013-2016 questionnaires show.
“One of the findings that surprised us the most was that for both men and women, about 80 percent of adults with depression had at least some difficulty with functioning with daily life,” said lead author Debra Brody.
These include going to work, completing daily activities at home and getting along with other people, said Brody, of the CDC’s National Center for Health Statistics (NCHS).
“This report should make people aware how serious depression is, and that it impacts everyday life,” she added.
According to Dr. David Roane, chairman of psychiatry at Lenox Hill Hospital in New York City, “The biggest issues with depression are diagnosis and treatment.”
In most cases, primary care doctors are able to diagnose depression, he noted. “But people often don’t get adequate treatment in terms of both medication and psychotherapy,” Roane said.
However, there are obstacles to treatment, he said. For one thing, people often don’t realize they are depressed, even if they have mood problems and changes in thinking.
Also, mental health problems are still often considered taboo. “The stigma related to depression has decreased somewhat, but it’s still a major issue for someone to be diagnosed with a mental health disorder,” he said. In addition, many cases of mild depression will resolve over time, so some patients don’t want treatment.
“The problem is that if you are having functional impairment, it can be highly disruptive to your life,” he said. “Six months is a long time to suffer from depression, and I don’t recommend that.”
It has been shown before that women are more prone to depression than men, but the reasons are not known, Roane said.
Data for the report was gathered from the U.S. National Health and Nutrition Examination Surveys. The findings were published online Feb. 13 in the CDC’s NCHS Data Brief.
For more about depression, visit the U.S. National Institute of Mental Health.
SOURCES: Debra Brody, M.P.H., division of Health and Nutrition Examination Surveys, National Center for Health Statistics (NCHS), U.S. Centers for Disease Control and Prevention; David Roane, M.D., chairman, psychiatry, Lenox Hill Hospital, New York City; Feb. 13, 2018, U.S. Centers for Disease Control and Prevention’s NCHS Data Brief, online
It is vital that you report any practice changes to ensure that we have your current address, phone, fax, and email address. Any changes or corrections to your TIN/name combination should be communicated immediately. The Provider Update tool withinChiroCare Connect offers a quick and electronic means to report changes. Simply select the “Billing Information Update” option within the Provider Update tool.
Please contact our Provider Services team at 877-886-4941 with any questions about submission of updates.