In this Issue:
- What is the value of a ChiroCare Centers of Excellence designation?
- 2018 Centers of Excellence Applications - Now Open!
- GA, GY or GZ Modifiers Notice
- Board of Directors Reappointment and Reelection Report
- Security Risk Assessments
- How and Why to Identify Measurable Goals for Patients in your Practice
- Financial Guidance for Your Small Business
- Moving or Retiring? Let us Know!
Healthcare in today’s world is focused on providing patient options that demonstrate high standards of quality and value. Consumers are demanding clinics that demonstrate this level of quality and affordability while primary care providers are seeking conservative care options to manage their patients’ back pain.
- Visibility as a Center of Excellence clinic on the Find a Doc tool located on ChiroCare.com.
- Position your clinic to be recognized for increased Pay for Performanceincentives.
- Recognized as a quality clinic, facilitating trust and referrals with other care practitioners and patients.
- Opportunities to participate in pilot projects demonstrating conservative care value.
The CCoE program highlights ChiroCare clinics who achieve and maintain the highest standards of patient-centered care through record keeping, documented outcome measures, and collaboration with other health care providers to achieve the Triple Aim in health care.
Attributes of Excellence
- Comprehensive Patient Intake and History
- Assessment and Outcome Tools
- Cognitive Behavioral Therapy
- Shared Decision Making
- Conservative Imaging
- Treatment Care Plans
- Coordination of Care Between Practitioners or Facilities
- Management of the Care Plan
- Established Referral List of Practitioners and Referral Procedures
- Active Care Instruction
- Patient Education on homecare and prevention
- Wellness Instruction
- Patient-Centered Approach to Care Plans and Care Management
- Demonstration of Collaboration with Other Practitioners
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 is open until March 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 email@example.com .
Current CCoE clinics are not required to send in an application but will be asked to participate in a verification review in early 2018.
Fulcrum Health is notifying providers of the billing process and necessary modifiers to use when appropriate notice of non-coverage has been given to Medicare plan members. Changes take effect accordingly: Quartz effective 1/1/18 and HealthPartners and UCare effective 3/1/18.
When the service is not a covered benefit or not expected to be a covered benefit, a GA or GY modifier is required. When services are a covered benefit and expected to be covered, the AT modifier is required indicating the care is active treatment (acute).
Modifiers are to be used as followed below:
Use this modifier in the following instances:
- You have determined that the item or service does not meet criteria and will not be covered, you have notified the member of this information, and you have obtained written member consent prior to rendering the non-covered item or service.
- If a pre-service organization determination is made to deny coverage and a Notice of Denial of Medical Coverage has been sent to the member prior to the non-covered item or service being rendered.
- You obtained written member consent prior to rendering the non-covered item or service.
We recommend notifying members using the Fulcrum Medicare Financial Disclosure form, Medicare Member Consent for Non-Covered Service Form. While it is recommended that providers utilize this form, providers may elect to use another version of a consent form however, it must include the following elements:
- Provider name.
- Provider address.
- Detailed list of non-covered services for which the member will be billed, and the cost associated with each. Note: Spinal manipulations that have not been denied through the organization determination process cannot be billed to the patient.
- Signature of the provider or health care representative who explained the Consent Form and discussed available options to the patient.
- Patient name.
- Patient signature. Note: The signature must be obtained prior to the service being rendered and updated when benefits change, or a maximum period of 12 weeks has lapsed.
- Date of patient signature. Note: The signature must be obtained prior to the service being rendered and updated when benefits change, or a maximum period of 12 weeks has lapsed.
A copy of the consent must be kept on file by the provider and provided to Fulcrum upon request.
If you bill Fulcrum for a non-covered service without the GA modifier, indicating appropriate written member consent has been obtained, the claim will be denied to provider liability and the member cannot be billed.
- Use this modifier when an item or service is never covered by Medicare and the Health Plan and is a clear benefit exclusion in the member’s health plan documents. Use of this modifier indicates to the plan that you have verbally communicated this information to the member and have clearly documented the communication in the patient’s medical record.
- If you bill Fulcrum for these never-covered services without using the GY modifier, the claim will be denied to provider liability and the member cannot be billed.
- The GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable and necessary, and 2) advance notice of non-coverage was not provided to the member. DO NOT USE THIS MODIFIER.
- All claims billed with the GZ modifier will deny to provider liability and the member cannot be billed.
In accordance with Fulcrum Health’s Bylaws, the board members listed below confirmed their desire to serve an additional three (3) year term beginning on January 1, 2018 and ending on December 31, 2021 as Directors of the Corporation. Election ballot forms were emailed to all voting members via Survey Monkey in October of 2017, and we are pleased to announce our reappointments and reelections.
- Scott Giltner
- Zach Kimble, DC
- Becky McManus
- Pete Vrieze, DC
- Paul Wernick, MD
For more information about Fulcrum’s Board of Directors, visit the Board of Directors section on our corporate website.
The Health Insurance Portability and Accountability Act (HIPAA) Security Rules require that covered entities, such as provider offices, conduct an annual risk assessment of their organization. This risk assessment helps ensure compliance with the physical, administrative and technical safeguards outlined by HIPAA.
While the Security Rule requires that all covered entities “Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information (EPHI) held by the [organization],” it does not provide specifics on how to conduct one or what to review in the assessment. The rule is intended to provide objectives that must be achieved. Luckily, there are many resources available to covered entities to help them get started with a risk assessment.
The Center for Medicare and Medicaid Services (CMS) has published documentation to help smaller organizations better understand and implement a risk assessment within their facility. In the seven-part series, Security Topics 6 and 7 are beneficial to smaller organizations/facilities.
Article #6 in the Security Series, “ Basics of Risk Analysis and Risk Management ,” focuses on the fundamentals of risk assessments by providing awareness of key terms, examples of process steps used to complete a risk assessment, and examples of risk management steps.
Article #7 in the series, “ Security Standards: Implementation for the Small Provider ,” focuses on conducting a risk assessment that is relevant to smaller facilities. This article provides many sample questions that smaller organizations may consider when conducting a risk assessment. This document also provides additional resources that may be utilized to conduct a risk assessment.
Another option for completing a risk assessment may be to hire an outside vendor/contractor that will come in and evaluate your facility. During a review conducted by a vendor/contractor, you can expect to provide them with access to your facility, policies and procedures. If this option works best for your organization, make sure that a Business Associate Agreement or Non-Disclosure Agreement is properly put into place. The type of agreement needed will be dependent upon what type of information the contractor/vendor will be seeing and/or using.
For more information on Security Risk Assessments, please visit the U.S. Department of Health and Human Services website .
As always, if you know or suspect FWA 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.).
If you have any non-PHI related questions, please direct them toCompliance@FulcrumHealthInc.org.
We hear from many doctors struggling to identify measurable goals that demonstrate patient progress with treatment. Vague goals such as “increase range of motion” or “increase activities of daily living” are not measurable unless a numeric value is included. This lack of demonstrated progress can create questions on whether the care is medically necessary.
Treatment goals must be specific to each individual patient’s condition, contain a measurable functional goal, and include a pain index to monitor the patient’s response to treatment. For example, if a patient identifies she can only sit for 30 minutes at a time, a short-term goal could be sitting for 1 hour at a time within 2 weeks, and the long-term goal as sitting a consecutive 8 hours or more within 6 weeks. When the measurable goal indicates the patient has stopped improving or plateaued, it signals the time to change the treatment plan, refer the patient, or transition the patient to maintenance care.
Usage of an outcome assessment tool (OAT) can assist with accurately measuring the loss or gain of functional goals and provide measurable progress. Examples of this tool include the neck and low back indexes, Oswestry, Primary Care Low Back Disability Questionnaire, Bournemouth, and Roland Morris Disability. An assortment of outcome assessment tools are located on ChiroCare Connect > Clinical Resources > Outcome Assessment Toolbox for your convenience.
Health care today is moving rapidly toward a model of demonstrating goals and progress associated with treatment, and this “value-based care” is defined by patients’ outcomes. The Centers for Medicare and Medicaid Services (CMS) has rolled out thePhysician Quality Reporting System (PQRS) as a step to collect outcomes. While this is a voluntary program today, indications are this may be a pay-for-performance model in the future.
There are a variety of reasons why a small business owner may seek advice and guidance from a CERTIFIED FINANCIAL PLANNER™ professional or CFP® professional. These may include investment management, key employee retention, business succession, tax, and retirement planning.
Fulcrum is collaborating with a subject-matter expert to highlight some of these topics in the ChiroCare News Flash throughout 2018.
To learn more about how a CFP® professional can be a valuable resource for you and your business, check out this article titled “Here's The Difference Between A Financial Advisor And Certified Financial Planner.”
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 within ChiroCare 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 (888) 638-7719 with any questions about submission of updates.