Saturday, August 9, 2014
Group Practice Liability Under the False Claims Act via AAPC
AAPC posted a really good article a few weeks back. I wanted to share with everyone...
Group Practice Liability Under the False Claims Act
June 10th, 2014
Under the False Claims Act (FCA), a healthcare facility or entity may be held liable for the conduct of its individual employees, or even the conduct of other entities with which the healthcare facility or entity contracts or associates. This is true even where the healthcare facility or group practice entity has no actual knowledgethat its employee or contracted entity was engaged in the preparation or submission of false claims.
The FCA requires “knowing” presentment of a claim containing a material falsity, but expressly provides (in 31 U.S.C. §3729(b)) that “no proof of specific intent to defraud is required.” The statute broadly defines the terms “knowing” and “knowingly” as including “actual knowledge,” “acts in deliberate ignorance of the truth or falsity” of the information submitted on the claim, or “acts in reckless disregard of the truth or falsity of the information” submitted on the claim form. That is, knowledge is imputed (assumed) where it can be shown that the entity acted with reckless indifference or deliberate ignorance.
For example, a single physician in a multi-physician practice group routinely up-codes claims. If the practice fails to take steps to ensure the validity of the claim data, or assumes a “see no evil” approach to billing, the group could be liable under the FCA for recklessly allowing false claims to be submitted, or for deliberately ignoring evidence that false claims were being submitted. Such allegations against the group are especially likely where the government or qui tam relator (i.e., “whistleblower”) is confident that it has a better chance of obtaining payment of penalties and damages from the facility. Even in cases where the group practice is not found to have sufficient knowledge, it likely will incur legal expenses to defend itself or the targeted party.
The Ninth Circuit Court of Appeals has held that providers who bill Medicare have a duty to familiarize themselves with the requirements for payment (see U.S. v. Mackby, 262 F.3d 821, 828 (9th Cir. 2001)). As a result, reporting in a manner clearly contradicted by statutory or regulatory payment provisions could lead to FCA liability.
Not only do hospitals and healthcare provider groups face substantial FCA liability as a result of the conduct of those that it employs, or with whom it contracts/associates, but a number of federal courts have held that there is no right to indemnification or contribution for FCA liability from either a co-defendant or from a third party where the indemnification claim is dependent on the finding of FCA liability by the party seeking indemnification. In other words, even if a single individual within the group is responsible for false claims, the group cannot recover the cost of defending itself and/or penalties from that individual.
Take Steps to Limit Liability
Healthcare providers must take deliberate steps to reduce FCA exposure due to the improper employee or contractor conduct. Specifically, employee and sub-contractor education in proper coding and documentation, as well as the relevant rules establishing conditions of payment, is critical. Additionally, an effective internal audit program will not only identify errors before they get out of hand, but will demonstrate the entity’s efforts at compliance, thereby mitigating the potential that recklessness or deliberate ignorance can be shown.
The bottom line: Physician groups can be held directly liable for their own failure to prevent submission of false claims, as well as indirectly where the costs of defending such an action fall to the entity. Moreover, because indemnification is not permitted, hospitals and physician groups should consider stepping up efforts at minimizing FCA liability to preclude the possibility of such an action ever occurring. This may include reconsidering any budget reductions in the area of staff (physicians/coders) education and training and internal audit and compliance programs.
Monday, July 7, 2014
Chiropractic Treatment - Subluxation Medicare Guidelines
Medicare's website is so full of information. I found this LCD to be very helpful since I actively bill for a chiropractor...
LCD ID L33518
LCD Title Chiropractic Services
AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2013 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
Jurisdiction Nevada
Original Effective Date For services performed on or after 09/16/2013
Revision Effective Date For services performed on or after 11/01/2013
Revision Ending Date 02/11/2014
Retirement Date N/A
Notice Period Start Date N/A
Notice Period End Date N/A
CMS National Coverage Policy Title XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§30.5 and 240, 240.1, 240.1.1, 240.1.2, 240.1.3, 240.1.4. 240.1.5. Addresses Chiropractor's Services and Chiropractic Services - General, respectively.
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §220. Addresses Chiropractic Services.
National policy limits the coverage of chiropractic services to the "hands on" manual manipulation of the spine for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943, CMT, extraspinal, one or more regions, is not a Medicare benefit.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.
No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor's order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.
Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation. However, an x-ray may be used for this purpose if the chiropractor so chooses.
The word "correction" may be used in lieu of "treatment." Also, a number of different terms composed of the following words may be used to describe manual manipulation as defined above:
- Spine or spinal adjustment by manual means;
- Spine or spinal manipulation;
- Manual adjustment; and
- Vertebral manipulation or adjustment.
In any case in which the term(s) used to describe the service performed suggests that it may not have been treatment by means of manual manipulation, the carrier analyst refers the claim for professional review and interpretation.
Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.
A subluxation may be demonstrated by an x-ray or by physical examination, as described below.
1. Demonstrated by X-Ray
An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary's health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
2. Demonstrated by Physical Examination
Evaluation of musculoskeletal/nervous system to identify:
- Pain/tenderness evaluated in terms of location, quality, and intensity;
- Asymmetry/misalignment identified on a sectional or segmental level;
- Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
- Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.
To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under "physical examination" are required, one of which must be asymmetry/misalignment or range of motion abnormality.
The history recorded in the patient record should include the following: - Symptoms causing patient to seek treatment;
- Family history if relevant;
- Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
- Mechanism of trauma;
- Quality and character of symptoms/problem;
- Onset, duration, intensity, frequency, location and radiation of symptoms;
- Aggravating or relieving factors; and
- Prior interventions, treatments, medications, secondary complaints.
A - Documentation Requirements: Initial Visit
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History as stated above.
2. Description of the present illness including:
- Mechanism of trauma;
- Quality and character of symptoms/problem;
- Onset, duration, intensity, frequency, location, and radiation of symptoms;
- Aggravating or relieving factors;
- Prior interventions, treatments, medications, secondary complaints; and
- Symptoms causing patient to seek treatment.
These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo),bone (osseo or osteo), rib (costo or costal) and joint (arthro)and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.
3. Evaluation of musculoskeletal/nervous system through physical examination.
4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
5. Treatment Plan: The treatment plan should include the following:
- Recommended level of care (duration and frequency of visits);
- Specific treatment goals; and
- Objective measures to evaluate treatment effectiveness.
6. Date of the initial treatment.
B - Documentation Requirements: Subsequent Visits
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History
- Review of chief complaint;
- Changes since last visit;
- System review if relevant.
2. Physical exam
- Exam of area of spine involved in diagnosis;
- Assessment of change in patient condition since last visit;
- Evaluation of treatment effectiveness.
3. Documentation of treatment given on day of visit.
The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine demonstrated by x-ray or physical exam as described above.
Most spinal joint problems may be categorized as follows:
1. Acute subluxation: A patient's condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression,of the patient's condition.
2. Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as in the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.
For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, contractors may deny, if appropriate, after medical review.
3. Maintenance therapy: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.
Maintenance therapy is not a covered benefit.
4. Exacerbations: An exacerbation is a temporary marked deterioration of the patient's condition due to flare-up of the condition being treated. This must be documented on the claim form and must be documented in the patient's clinical record, including the date of occurrence, nature of the onset or other pertinent factors that will support the reasonableness and necessity of treatments for this condition.
5. Recurrence: A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 30 or more days. This may require the reinstitution of therapy.
6. Contraindications: Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement.
A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are relative contraindications to dynamic thrust:
● Articular hypermobility and circumstances where the stability of the joint is uncertain; ●Severe demineralization of bone; ● Benign bone tumors (spine); ● Bleeding disorders and anticoagulant therapy; and ● Radiculopathy with progressive neurological signs.
Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:
● Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
● Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
● An unstable odontoideum;
● Malignancies that involve the vertebral column;
● Infection of bones or joints of the vertebral column;
● Signs and symptoms of myelopathy or cauda equina syndrome;
● For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and
● A significant major artery aneurysm near the proposed manipulation.
Location of Subluxation:
The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified:
Area of Spine - Names of Vertebrae - Number of Vertebrae - Short Form or Other Name
Neck - Occiput (Occ, CO), Cervical (C1 thru C7), Atlas (C1), Axis (C2) - 7
Back - Dorsal (D1 thru D12) or Thoracic (T1 thru T12) or Costovertebral (R1 thru R12) or Costotransverse (R1 thru R12) - 12
Low Back - Lumbar (L1 thru L5) - 5
Pelvis - Iiii, r and l (I, Si)
Sacral - Sacrum, Coccyx, S, SC
In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment.
There are two ways in which the level of the subluxation may be specified: - The exact bones may be listed, for example: C5, C6, etc.
- The area may suffice if it implies only certain bones such as: Occipito-atlantal (occiput and C1 (atlas)),
lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).
Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:
- Off-centered
- Misalignment
- Malpositioning
- Spacing - abnormal, altered, decreased, increased
- Incomplete dislocation
- Rotation
- Listhesis - antero, postero, retro, lateral, spondylo
- Motion - limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant
Other terms may be used. If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.
Treatment Parameters
The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.
Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already "set" and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.
Some chiropractors have been identified as using an "intensive care" concept of treatment. Under this approach multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
LCD ID L33518
LCD Title Chiropractic Services
AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2013 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
Jurisdiction Nevada
Original Effective Date For services performed on or after 09/16/2013
Revision Effective Date For services performed on or after 11/01/2013
Revision Ending Date 02/11/2014
Retirement Date N/A
Notice Period Start Date N/A
Notice Period End Date N/A
CMS National Coverage Policy Title XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.
CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§30.5 and 240, 240.1, 240.1.1, 240.1.2, 240.1.3, 240.1.4. 240.1.5. Addresses Chiropractor's Services and Chiropractic Services - General, respectively.
CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §220. Addresses Chiropractic Services.
National policy limits the coverage of chiropractic services to the "hands on" manual manipulation of the spine for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943, CMT, extraspinal, one or more regions, is not a Medicare benefit.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.
No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor's order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.
Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation. However, an x-ray may be used for this purpose if the chiropractor so chooses.
The word "correction" may be used in lieu of "treatment." Also, a number of different terms composed of the following words may be used to describe manual manipulation as defined above:
- Spine or spinal adjustment by manual means;
- Spine or spinal manipulation;
- Manual adjustment; and
- Vertebral manipulation or adjustment.
In any case in which the term(s) used to describe the service performed suggests that it may not have been treatment by means of manual manipulation, the carrier analyst refers the claim for professional review and interpretation.
Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.
A subluxation may be demonstrated by an x-ray or by physical examination, as described below.
1. Demonstrated by X-Ray
An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary's health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
2. Demonstrated by Physical Examination
Evaluation of musculoskeletal/nervous system to identify:
- Pain/tenderness evaluated in terms of location, quality, and intensity;
- Asymmetry/misalignment identified on a sectional or segmental level;
- Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
- Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.
To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under "physical examination" are required, one of which must be asymmetry/misalignment or range of motion abnormality.
The history recorded in the patient record should include the following: - Symptoms causing patient to seek treatment;
- Family history if relevant;
- Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
- Mechanism of trauma;
- Quality and character of symptoms/problem;
- Onset, duration, intensity, frequency, location and radiation of symptoms;
- Aggravating or relieving factors; and
- Prior interventions, treatments, medications, secondary complaints.
A - Documentation Requirements: Initial Visit
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History as stated above.
2. Description of the present illness including:
- Mechanism of trauma;
- Quality and character of symptoms/problem;
- Onset, duration, intensity, frequency, location, and radiation of symptoms;
- Aggravating or relieving factors;
- Prior interventions, treatments, medications, secondary complaints; and
- Symptoms causing patient to seek treatment.
These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo),bone (osseo or osteo), rib (costo or costal) and joint (arthro)and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.
3. Evaluation of musculoskeletal/nervous system through physical examination.
4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
5. Treatment Plan: The treatment plan should include the following:
- Recommended level of care (duration and frequency of visits);
- Specific treatment goals; and
- Objective measures to evaluate treatment effectiveness.
6. Date of the initial treatment.
B - Documentation Requirements: Subsequent Visits
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History
- Review of chief complaint;
- Changes since last visit;
- System review if relevant.
2. Physical exam
- Exam of area of spine involved in diagnosis;
- Assessment of change in patient condition since last visit;
- Evaluation of treatment effectiveness.
3. Documentation of treatment given on day of visit.
The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine demonstrated by x-ray or physical exam as described above.
Most spinal joint problems may be categorized as follows:
1. Acute subluxation: A patient's condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression,of the patient's condition.
2. Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as in the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.
For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, contractors may deny, if appropriate, after medical review.
3. Maintenance therapy: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.
Maintenance therapy is not a covered benefit.
4. Exacerbations: An exacerbation is a temporary marked deterioration of the patient's condition due to flare-up of the condition being treated. This must be documented on the claim form and must be documented in the patient's clinical record, including the date of occurrence, nature of the onset or other pertinent factors that will support the reasonableness and necessity of treatments for this condition.
5. Recurrence: A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 30 or more days. This may require the reinstitution of therapy.
6. Contraindications: Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement.
A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are relative contraindications to dynamic thrust:
● Articular hypermobility and circumstances where the stability of the joint is uncertain; ●Severe demineralization of bone; ● Benign bone tumors (spine); ● Bleeding disorders and anticoagulant therapy; and ● Radiculopathy with progressive neurological signs.
Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:
● Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
● Acute fractures and dislocations or healed fractures and dislocations with signs of instability;
● An unstable odontoideum;
● Malignancies that involve the vertebral column;
● Infection of bones or joints of the vertebral column;
● Signs and symptoms of myelopathy or cauda equina syndrome;
● For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and
● A significant major artery aneurysm near the proposed manipulation.
Location of Subluxation:
The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified:
Area of Spine - Names of Vertebrae - Number of Vertebrae - Short Form or Other Name
Neck - Occiput (Occ, CO), Cervical (C1 thru C7), Atlas (C1), Axis (C2) - 7
Back - Dorsal (D1 thru D12) or Thoracic (T1 thru T12) or Costovertebral (R1 thru R12) or Costotransverse (R1 thru R12) - 12
Low Back - Lumbar (L1 thru L5) - 5
Pelvis - Iiii, r and l (I, Si)
Sacral - Sacrum, Coccyx, S, SC
In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment.
There are two ways in which the level of the subluxation may be specified: - The exact bones may be listed, for example: C5, C6, etc.
- The area may suffice if it implies only certain bones such as: Occipito-atlantal (occiput and C1 (atlas)),
lumbo-sacral (L5 and Sacrum), sacro-iliac (sacrum and ilium).
Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:
- Off-centered
- Misalignment
- Malpositioning
- Spacing - abnormal, altered, decreased, increased
- Incomplete dislocation
- Rotation
- Listhesis - antero, postero, retro, lateral, spondylo
- Motion - limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant
Other terms may be used. If they are understood clearly to refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.
Treatment Parameters
The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.
Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already "set" and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.
Some chiropractors have been identified as using an "intensive care" concept of treatment. Under this approach multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
Tuesday, January 14, 2014
Nationwide Enrollment for Health Care Coverage Surged in December
WOW! It has been a busy Fall and Winter for us at Simplified Medical Billing! I would like to start the New Year off with an article found regarding Obamacare enrollment numbers. Have you signed up for the new plan? If so we would love to hear what you think of your new insurance plan. Here is to wishing everyone a happy and safe 2014!
Nationwide Enrollment for Health Care Coverage Surged in December
By Marilyn Tavenner, Administrator, Centers for Medicare & Medicaid Services Posted December 31, 2013
Nationwide Enrollment for Health Care Coverage Surged in December
By Marilyn Tavenner, Administrator, Centers for Medicare & Medicaid Services Posted December 31, 2013
Since the beginning of open enrollment, millions of Americans are gaining access to health coverage–many for the very first time—thanks to the Affordable Care Act. The most recent data indicate that more than 2.1 million people have enrolled in a private health insurance plan through the Federal and State-based Marketplaces since October 1.
Both states and the federal government have seen a surge in enrollment in December. Our HealthCare.gov enrollment nearly doubled in days before the January 1 coverage deadline compared to the first weeks of the month. Nationwide, including state and federal marketplaces, December enrollment so far is nearly 6 times that of October and November combined.
We expect these numbers to continue to grow through the end of March when open enrollment ends.
Additionally, 3.9 million Americans learned they’re eligible for coverage through Medicaid and the Children’s Health Insurance Program (CHIP) in October and November. These numbers include new eligibility determinations and some Medicaid and CHIP renewals.
We are encouraged that over 6 million people have been enrolled in Marketplace or Medicaid coverage since October 1, and will work to give millions more Americans the peace of mind that comes with health security in the months ahead.
Monday, August 19, 2013
"Medicaid Moving Forward"
I found some great news for adults in AZ in need of Medicaid. Gov. Brewer signed a new law and it looks like many childless adults will be able to qualify for ins by the 1st of 2014. Check out this article and link below!!
Click Here for Direct Link to Article
Medicaid Moving Forward
Background
The Supreme Court ruling on the Affordable Care Act (ACA) provides states multiple and complex opportunities with respect to the future of their Medicaid programs. With these opportunities in mind, Governor Brewer signed into law the AHCCCS Restoration Plan which restores coverage to thousands of Childless Adults and provides coverage for those between 100-133% of the Federal Poverty Level, beginning January 1, 2014. The links below provide detailed information regarding the impact of these provisions to Arizona’s Medicaid program. Additional information will be posted to this page as soon as it becomes available.
The AHCCCS Strategic Plan identifies four goals critical to sustain and build on the success of the AHCCCS program in light of the restoration of coverage -- the most important healthcare policy issue the State has faced since the inception of the AHCCCS program 30 years ago and can be found on the link below:
AHCCCS Strategic Plan 2014-2018
Public Input Process
AHCCCS will be involved in a variety of stakeholder efforts to inform and accept feedback from the public regarding Medicaid Moving Forward. Information will be posted as soon as it becomes available. Questions and comments can be sent to Forward@azahcccs.gov. •Public Meetings New AHCCCS is hosting community meetings across the state to provide the public with information about some of the upcoming changes for Arizona’s Medicaid program. These sessions will also provide the opportunity for AHCCCS to hear from stakeholders, including members and their families, advocates and providers. Space is limited so RSVP is required. Information about these meetings can be found at the link below.
Public Meetings
•Stay Connected
If you would like to receive periodic updates about AHCCCS, implementation, future public meetings or other information, please email Forward@azahcccs.gov. You can also add your name to continue to show support for Restoration and it will automatically place you on the email list. To sign your name in support, please visit the web page below:
I Support Medicaid Coverage
AHCCCS Topics of Interest
•Medicaid Coverage
On June 17, 2013, Governor Brewer signed into law her Medicaid Restoration Plan. Adult coverage will begin January 1, 2014 and applications accepted and processed beginning October 1, 2013. Applicants are encouraged to use the Health-e-Arizona Plus online application to apply. The link below provides background information about how this plan was developed and how it will be funded.
Medicaid Coverage
Hospital Assessment
Moving Forward Presentation
•KidsCare Coverage
Enrollment for Arizona’s CHIP program, known as KidsCare, will remain frozen in 2014 and authority for the KidsCare II program ends December 31, 2013. However, families with income up to 400% FPL may receive premium subsidies for commercial coverage on the Federally Facilitated Marketplace. More information is located on the link below.
KidsCare Coverage
•Health-e-Arizona Plus
AHCCCS and DES are leveraging the current Health-e-Arizona system to comply with new requirements for Medicaid and CHIP eligibility. Health-e-Arizona Plus will be available 10/1/13. Click on the link below for more information.
Modernizing Medicaid IT Systems
•Federally Facilitated Marketplace
On November 18, 2012, Governor Brewer announced that Arizona will participate in a Federally Facilitated Marketplace (FFM). More information on the Governor’s decision can be found below. A link to the Marketplace Subsidy Calculator is also included, which helps estimate premiums and subsidies for people purchasing insurance through the Marketplace. More information on the FFM can be found at www.healthcare.gov.
Marketplace Decision Letter- 11/28/12
Marketplace Subsidy Calculator
Cover AZ
•Essential Health Benefits
Governor Brewer selected the State Employee Benefit- United Healthcare EPO with pediatric, dental and vision coverage supplemented by the FED-VIP as the baseline Essential Health Benefits package for Arizona. The Essential Health Benefits package mandates the minimum services for all commercial policies in Arizona. More information can be found on the links below:
Essential Health Benefits
Governor Brewer Letter 9/28/12
Although Arizona is no longer accepting public comments regarding the Essential Health Benefits Benchmark Plan, a link to the Essential Health Benefits Report can be found below. Comments were originally submitted electronically to: HIX@az.gov.
Benchmark Plan Report
•Federal Interface
CMS has released information regarding the ACA’s provisions and can be found on the links below. Further discussion with CMS will continue and the information posted as soon as it becomes available. More information can be found at www.CMS.gov.
Comments on Proposed Rules
Final Rules
State Plan Amendments
Click Here for Direct Link to Article
Medicaid Moving Forward
Background
The Supreme Court ruling on the Affordable Care Act (ACA) provides states multiple and complex opportunities with respect to the future of their Medicaid programs. With these opportunities in mind, Governor Brewer signed into law the AHCCCS Restoration Plan which restores coverage to thousands of Childless Adults and provides coverage for those between 100-133% of the Federal Poverty Level, beginning January 1, 2014. The links below provide detailed information regarding the impact of these provisions to Arizona’s Medicaid program. Additional information will be posted to this page as soon as it becomes available.
The AHCCCS Strategic Plan identifies four goals critical to sustain and build on the success of the AHCCCS program in light of the restoration of coverage -- the most important healthcare policy issue the State has faced since the inception of the AHCCCS program 30 years ago and can be found on the link below:
AHCCCS Strategic Plan 2014-2018
Public Input Process
AHCCCS will be involved in a variety of stakeholder efforts to inform and accept feedback from the public regarding Medicaid Moving Forward. Information will be posted as soon as it becomes available. Questions and comments can be sent to Forward@azahcccs.gov. •Public Meetings New AHCCCS is hosting community meetings across the state to provide the public with information about some of the upcoming changes for Arizona’s Medicaid program. These sessions will also provide the opportunity for AHCCCS to hear from stakeholders, including members and their families, advocates and providers. Space is limited so RSVP is required. Information about these meetings can be found at the link below.
Public Meetings
•Stay Connected
If you would like to receive periodic updates about AHCCCS, implementation, future public meetings or other information, please email Forward@azahcccs.gov. You can also add your name to continue to show support for Restoration and it will automatically place you on the email list. To sign your name in support, please visit the web page below:
I Support Medicaid Coverage
AHCCCS Topics of Interest
•Medicaid Coverage
On June 17, 2013, Governor Brewer signed into law her Medicaid Restoration Plan. Adult coverage will begin January 1, 2014 and applications accepted and processed beginning October 1, 2013. Applicants are encouraged to use the Health-e-Arizona Plus online application to apply. The link below provides background information about how this plan was developed and how it will be funded.
Medicaid Coverage
Hospital Assessment
Moving Forward Presentation
•KidsCare Coverage
Enrollment for Arizona’s CHIP program, known as KidsCare, will remain frozen in 2014 and authority for the KidsCare II program ends December 31, 2013. However, families with income up to 400% FPL may receive premium subsidies for commercial coverage on the Federally Facilitated Marketplace. More information is located on the link below.
KidsCare Coverage
•Health-e-Arizona Plus
AHCCCS and DES are leveraging the current Health-e-Arizona system to comply with new requirements for Medicaid and CHIP eligibility. Health-e-Arizona Plus will be available 10/1/13. Click on the link below for more information.
Modernizing Medicaid IT Systems
•Federally Facilitated Marketplace
On November 18, 2012, Governor Brewer announced that Arizona will participate in a Federally Facilitated Marketplace (FFM). More information on the Governor’s decision can be found below. A link to the Marketplace Subsidy Calculator is also included, which helps estimate premiums and subsidies for people purchasing insurance through the Marketplace. More information on the FFM can be found at www.healthcare.gov.
Marketplace Decision Letter- 11/28/12
Marketplace Subsidy Calculator
Cover AZ
•Essential Health Benefits
Governor Brewer selected the State Employee Benefit- United Healthcare EPO with pediatric, dental and vision coverage supplemented by the FED-VIP as the baseline Essential Health Benefits package for Arizona. The Essential Health Benefits package mandates the minimum services for all commercial policies in Arizona. More information can be found on the links below:
Essential Health Benefits
Governor Brewer Letter 9/28/12
Although Arizona is no longer accepting public comments regarding the Essential Health Benefits Benchmark Plan, a link to the Essential Health Benefits Report can be found below. Comments were originally submitted electronically to: HIX@az.gov.
Benchmark Plan Report
•Federal Interface
CMS has released information regarding the ACA’s provisions and can be found on the links below. Further discussion with CMS will continue and the information posted as soon as it becomes available. More information can be found at www.CMS.gov.
Comments on Proposed Rules
Final Rules
State Plan Amendments
Wednesday, July 24, 2013
Cigna - Patient Billing Reminder
I received a great piece of news today from Cigna. Their July 2013 Network News article was filled with a lot of good information. This is one piece I thought worth sharing because there is always a question of when and how much to collect from a patient. This helps clarify that for their networks.
http://www.cigna.com/customer_care/healthcare_professional/newsletters/July_2013/billing-0713
Patient billing reminder
It is important to remember that there are program requirements and administrative guidelines in place that include how and when to bill your Cigna patients for covered services. As outlined in the Denied Payment and Participant Non-liability section of the Cigna Reference Guide for physicians, hospitals, ancillaries, and other health care professionals, if these requirements and guidelines are not followed, payment cannot be recovered by charging the patient for the covered services.
Coinsurance plans
For your Cigna patients with a coinsurance plan (a deductible plan or a plan that requires individuals to pay a percentage of the covered charges after meeting the deductible amount), submit claims to Cigna (or its designee). If you used the Cigna Cost of Care Estimator®, you may bill the patient for the amount inidicated as their payment responsibility. Otherwise, you will receive an explanation of payment (EOP) indicating the individual’s payment responsibility. Refer to this EOP before you bill your patients.
Copay plans
For your Cigna patients with a copay plan (a fixed dollar amount they owe per service), the applicable copays may be collected at the time of service. Refer to your patients’ Cigna ID card for the copay amount.
To ensure proper billing, please be aware of these requirements. Log in to CignaforHCP.com > Resources > Reference Guides > Medical Reference Guides > Health Care Professional Reference Guides for information on billing requirements.
http://www.cigna.com/customer_care/healthcare_professional/newsletters/July_2013/billing-0713
Monday, April 1, 2013
AZ BCBS Implementing New Duplicate Denial Reasons
www.azblue.com
I received an email today from BCBS... Good to know info ;-)
Please visit their website or call them if you have any questions or concerns regarding the information listed below.
NEW DUPLICATE CLAIM DENIAL REASONS
BCBSAZ has recently implemented new and more informative duplicate denial reasons. Our hope is that the new denial reasons will provide a better explanation as to why your claim was considered a duplicate and will assist you in determining what action may need to be taken. Please see the attachment for a sample of the new duplicate denial reason code narratives.
The process for corrected claims and grievances apply to a single claim for a specific member. However, if you have more than 10 claim corrections and grievances for the same situation please contact your network contract specialist.
If you are unable to submit corrected claims or grievances electronically submit a completed Corrected Claim Form or Provider Grievance Form. From the azblue.com “Providers” tab on the public home page on the right side, look under the category Quick Links and select Forms & Resources to be directed to the online forms. The online Corrected Claim and Grievance forms can also be found in the secured provider portal as well as in the Provider Operating Guide.
We encourage providers to file corrected claims and grievances electronically since there are many benefits to filing electronically:
I received an email today from BCBS... Good to know info ;-)
Please visit their website or call them if you have any questions or concerns regarding the information listed below.
NEW DUPLICATE CLAIM DENIAL REASONS
BCBSAZ has recently implemented new and more informative duplicate denial reasons. Our hope is that the new denial reasons will provide a better explanation as to why your claim was considered a duplicate and will assist you in determining what action may need to be taken. Please see the attachment for a sample of the new duplicate denial reason code narratives.
When
researching a claim that has denied as being a duplicate, please log into
“BlueNet” and access the Online Remit link found on the provider portal under
the Claims Management tab. Only the online remittance will provide you
with the new specific reasons as to why BCBSAZ considered the claim to be a
duplicate. The electronic remittance advice (ERA) will only display the ANSI
standard duplicate reason code.
After
your review, determine what steps may be needed using the instructions outlined
below:
-
If the original claim information was wrong or in-complete, submit a corrected claim or an E-adjustment. Do not send a new claim.
-
Or; if you’ve confirmed the claim was in fact not a duplicate and you believe NO change or correction is required, follow the process for filing a formal grievance.
The process for corrected claims and grievances apply to a single claim for a specific member. However, if you have more than 10 claim corrections and grievances for the same situation please contact your network contract specialist.
BCBSAZ
requests that corrected claims and grievances be submitted electronically via
the BlueNet provider
portal. From the secure provider portal homepage, click on the Claims
Management tab. Next, click on the Claim Status link to perform a claim status
look up. Select the appropriate claim that you determine needs to be corrected
or grieved and then click on either the Claim Action request Form to file a
corrected claim or the Appeal Form to submit a grievance.
If you are unable to submit corrected claims or grievances electronically submit a completed Corrected Claim Form or Provider Grievance Form. From the azblue.com “Providers” tab on the public home page on the right side, look under the category Quick Links and select Forms & Resources to be directed to the online forms. The online Corrected Claim and Grievance forms can also be found in the secured provider portal as well as in the Provider Operating Guide.
We encourage providers to file corrected claims and grievances electronically since there are many benefits to filing electronically:
- Reduces paper handling and simplifies the process
- Expedites your request
- Allows provider to attach documentation necessary to support your request
- Allows providers to track Claims Corrections and Grievances submitted via the online Confirmation page
For
more details on the types of transactions that can be filed electronically refer
to “Doing Business
Electronically”
and the “Electronic Adjustment User Guide”.
|
examples
of New Duplicate denial Reason codes
|
Provider
Action
|
|
BCBSAZ
denied this claim because the remarks submitted with the claim show it as a
correction to a previously filed claim. It needs to be submitted as an
adjustment.
Please
resubmit this claim using the claim frequency code 7 or 8. Refer to the
corrected claim form to see if medical records are also
needed.
|
The
duplicate claim was submitted indicating a correction was needed. After
reviewing the claim, if a correction is needed providers need to submit a
corrected claim or an e-adjustment using the claim frequency code 7 or 8.
|
|
BCBSAZdenied
payment for this claim as a possible duplicate. BCBSAZ has already processed a
claim for this same member, provider, service and date.
If
the patient was seen more than once in the same emergency room on the same date,
the claim should be billed with condition code g0 or modifier 27.
|
After
reviewing the claim it is determined that the patient was seen more than once in
the emergency room on the same date, the claim that was denied for being a
duplicate should be submitted as a corrected claim adding condition code g0 or
modifier 27
|
|
BCBSAZ
denied payment for this claim as a possible duplicate of a previously processed
claim for the same date, provider, and service.
Although
the prior claim has a different diagnosis, to change the claim, you must submit
a corrected claim with medical records, supporting documentation and the reason
for the change or correction. BCBSAZ can take no further action on this claim
until this information is submitted.
|
After
reviewing the claim if the prior processed claim should have had a different
diagnosis submit a corrected claim or e-adjustment.
If
you’ve confirmed the claim was not a duplicate and no change or correction is
required, follow the process for filing a formal grievance.
Medical
records and/or, supporting documentation must be submitted in both instances.
|
|
BCBSAZ
has denied this claim as a duplicate of a prior claim for which BCBSAZ requested
medical records.
BCBSAZ
has not received the requested records, and cannot process any claims for these
services without those records. Please submit the requested records.
|
Providers
should not submit a new claim. Submit only the medical records requested
attached to the letter we sent you requesting the information needed. Please
read the record request letter from us carefully and include all items
requested.
|
|
This
is a duplicate of a previously submitted claim for which BCBSAZ requested
medical records. We will use the submitted records to complete processing of the
initial claim.
For
record keeping purposes, we must deny this claim as a duplicate, but it will not
affect the processing of the initial claim.
|
Providers
should not submit a new claim.
The
initial claim will be reviewed and determination will be provided after medical
review is completed
|
Thursday, March 7, 2013
3 Tips Guide Successful Incident-to Billing
3 Tips Guide Successful Incident-to Billing
The patient must be established, with an established problem or complaint
Per the Medicare Benefits Manual, Chapter 15, Section 60.1, incident to services “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.”
Practically speaking, this means the physician or qualified NPP must have seen the patient previously for the problem or complaint for which the incident to service was provided. New patients, or those with a new problem, cannot be seen incident to.
The physician does not have to provide a personal professional service each time the patient is seen incident to, but neither can the physician “turn over” care of the patient to auxiliary staff. He or she must remain directly involved with the patient’s care, or—as the Benefits Manual states—“there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.”
Services must be medically necessary and appropriate in the physician office
The Benefits Manual states it this way: “Where supplies are clearly of a type a physician is not expected to have on hand in his/her office, or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.”
Direct supervision is required
Incident to coverage “is limited to situations in which there is direct physician supervision of auxiliary personnel,” per the Benefits Manual. Direct supervision means the physician must be present in the office suite and immediately available to provide assistance and direction. The incident to service should be billed in the supervision physician’s name.
Auxiliary personnel means any individual who is acting under the supervision of a physician, “regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician.”
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