Everyone’s job description should include knowledge and understanding of a patient’s insurance

As a consultant and instructor for the past 15 years, it never ceases to amaze me that in most chiropractic offices, only 1 person knows insurance. Whether the office has 3 employees or 15 employees, generally speaking only 1 person is in charge of correct coding and insurance filing. Usually, this person is not the DC.

How much stress does this put on one individual? What happens to the office when this person is out sick or off on vacation? How much power does this give one individual? I have often heard DCs confess that they cannot fire a certain individual, because that person is the only one who knows about insurance. Whose fault is that?

Today’s chiropractic office is a business that typically survives on insurance billing and knowledge of coding and documentation. Letting one person assume this responsibility is not only risky, it is poor business management.

Everyone’s Job Description
Everyone’s job description should include knowledge and understanding of a patient’s insurance. From the front desk to the back office, every employee encounters patients with questions. The worst response to a patient’s concern is, “I don’t know.” Even if the back office assistant does not actually file insurance or have firsthand knowledge of the patient’s case, she should never dismiss a patient’s question with such a flippant response. A more appropriate answer would be, “Mrs Jones, I’m sure Becky can help you with that question. Let me ask her to come in and speak to you about that.”

Patients need to feel reassured and comfortable that your office staff knows how to file and collect their insurance benefits. If the front desk assistant does not know the difference between a primary and secondary carrier, a patient will quickly lose faith in the competency of the office. Even when an office has specifically assigned job duties and responsibilities, it should be within everyone’s capability to assist and assure a patient that his or her insurance is being filed properly and accurately.

Also, when patients do not believe that an office has filed their insurance appropriately, they will be less likely to pay their portion of the account and more likely to dispute unpaid charges. Patients are more apt to complain to state or federal agencies regarding their bills if a staff member has treated them rudely or arrogantly.

Coding: An Achilles’ Heel
Properly billing for services rendered is one of the weakest links in insurance collection. Up coding, down coding, and miscoding are all forms of insurance fraud. If the front desk CA is responsible for entering services into the computer, and that individual does not know the difference between a 99202 and a 99212, the office has a problem. If the back office CA checks off a fee slip and inappropriately bills a modality therapy (97014) as a one-on-one therapy (97032), fraud just occurred in the billing. When a DC allows the insurance CA to decide on which current procedural terminology (CPT) code to bill based on the type of insurance carrier, he or she could face an audit with serious consequences.

Every employee should understand the basics of service billing. Every service performed in your office has an attached CPT or Healthcare Common Procedure Coding System (HCPCS) code. While understanding the idiosyncrasies of coding may be difficult, understanding the fundamentals of service-related nomenclature does not have to be. Most employees dummy down their understanding because they think it is too hard to learn, or in some cases, the insurance CA has put the fear of knowledge into their heads. It is called job security when only one person knows the rules. It is called good business to have employees at least understand the service coding in their own area.

In therapy, for example, each therapy machine may have a label stuck on it designating the CPT code to be used when that therapy is administered, or a chart explaining the coding if the service is a time-sensitive code. Each back office CA should know the difference between a modality, a procedure, and an activity. They should understand what one-on-one means and how to code for group therapies if necessary. Since back office CAs normally assist in the therapy, they must understand how their charting will affect the service billed. (Not documented, not done.) If a back office CA is responsible for taking x-rays, she must understand the aspect of unbundling an x-ray series in coding.

DCs should be responsible for properly coding their own services. This includes the type and level of exam and manipulation rendered. This task cannot be assigned to an insurance person who does not have firsthand knowledge of the service being performed. Evaluation and Management (E/M) codes involve a level of medical decision-making that only the DC can justify. If doctors understood the requirements necessary for billing the different levels of CPT codes, there would be less risk of up coding for services that cannot be substantiated.

Front desk CAs should know enough about the coding to double-check the CPT codes indicated on the fee slip. If the back office CA and the DC have inappropriately checked the wrong CPT code, it should be caught at the front desk before it is entered into the computer. At the very least, the front desk CA should be able to question the correctness of the service rendered or coded and should not take each fee slip for granted in its accuracy. The insurance CA then should double-check each claim for CPT, ICD-9, and documentation errors. It is easier to find and correct a mistake in-house, before the claim is filed, than to have to correct a claim form that is being questioned by the carrier.

Staff Education
“We are all in this together,” should be every office’s motto. Everyone’s paycheck depends on the financial viability of the clinic. Without the proper coding and insurance knowledge, reimbursement suffers, patient confidence suffers, and the growth and success of the entire clinic is compromised. This awesome responsibility cannot be left to only one individual.

When an insurance or coding seminar is offered, don’t just send the insurance person. Some offices think that they cannot afford to send everyone. The truth is, you cannot afford to not train everyone.

The Bare Minimum
Each individual working in a chiropractic office should know insurance definitions. He or she should know the difference between an insured and a dependent, and between a primary and secondary carrier. Everyone should have a working understanding of the different types of policies: Medicare, Medicaid, Workers’ Compensation, auto accident (PIP, Med-Pay, or Liability), personal injury (such as slip-and-fall, or homeowners), private pay, HMO, PPO, managed care, major medical, and third-party reimbursement. Staffers should understand what it means when an attorney is involved in a case, and how to address questions about a patient’s account over the phone.

Employees responsible for providing services to patients should know which service code is used to bill for the service provided. They should know how to determine “time” for one-on-one codes, the distinction of which services require a modifier, and the basics of CCI edits (Correct Coding Initiative—bundling services).

DCs should know how their documentation affects the level of service billed. They should also be fully knowledgeable about the use of ICD-9 (diagnosis) coding, and how linking services rendered to a diagnosis is essential for reimbursement. DCs must write treatment plans and be cognizant that services being billed follow said treatment plans.

Although most offices may depend on one person (the insurance clerk) to file and follow up on insurance claims, coding and billing is everyone’s responsibility. A DC is ultimately responsible for inappropriate or fraudulent claims, but the Federal False Claim Act (31 USC 3729-3733) also states that anyone “who knew, or should have known” of improper billing procedures may also be held legally responsible for committing fraud. This includes staff members.

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. She can be reached via email: naca_csoyring@yahoo.com.