Patient Confusion on Chiropractors and Physical Therapists

Posted by on Feb 13, 2015 in Health Care

By Traci Payne For anyone trying to understand a medical record or condition — including patients — it helps to take a look at definitions and how they’re applied: The American Chiropractic Association defines chiropractic this way: “Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuro-musculoskeletal complaints.” Chiropractic therapies mainly consist of pain management through adjustment manual manipulation ranging from soft tissue mobilization to joint adjustment, electrical stimulation and acupuncture. The American Physical Therapy Association defines physical therapy as: “Physical therapists are health care professionals who maintain, restore, and improve movement, activity, and health enabling individuals of all ages to have optimal functioning and quality of life, while ensuring patient safety and applying evidence to provide efficient and effective care.” Physical therapies have a much broader base within their systems — not just for pain relief but for rehabilitation focused with restoration of function and prevention of disabilities following disease, injury, or loss of a body part. These practitioners use several techniques to achieve this goal, including exercise, strengthening muscles, encouraging improved range of motion and retraining individuals to perform activities of daily living. While both professions promote healing, it’s important to remember the differences.  The Chiropractor focuses on manipulation on the musculoskeletal and spinal system, and the Physical Therapist focuses on maintaining, restoring and improving movement of musculoskeletal and neuromuscular systems through strengthening programs. Another significant difference relates to access.  Chiropractors are accessible to the general public, whereas a medical referral is required for physical therapy, including possible limits ordered by the physician to the amount of care rendered. There’s good news for patients in this arena.  Some states now  allow direct access of patients to doctors of physical therapy (DPT’s), thereby improving patient access. A Final Thought Most confusion about chiropractic and physical therapy is a result of how these two very different professions overlap in their treatment of the spine.  While a Chiropractor remains the King of Spinal Manipulation, the Physical Therapist is the King of Physical Rehabilitation through exercise, activity modification and muscle strengthening. Traci Payne is Account Coordinator/Operations Liaison with MKC Medical Management.  Contact her at...

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Fraud in the Healthcare System

Posted by on Feb 23, 2014 in Best Practices, Blog, Health Care, Legal Nurse Consultant, Legal Nurse Consulting, Litigation Tools

Better Education and Technical Know-how Can Combat the High Cost of Fraud The FBI estimates that healthcare fraud costs the country an estimated $80 billion a year!  It’s the Number One factor responsible for the country’s astronomical increases in healthcare costs. Fraud defined The National Health Care Anti-Fraud Association says that healthcare fraud is “an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual or the entity or to some other party.” Fraud and abuse can come in many forms.  It can include acts (and inaction) committed by providers as well as patients.  Providers may, for example… Bill for services not provided Duplicate submission of claim for same service, Misrepresent the service provided, and Bill for a covered service when the service provided was actually not covered Plan Members may abuse the system by… Doctor shopping Filing for reimbursement on services or medications not received or performed Falsification of information or injury Forging or selling prescription drugs, and Using transportation benefit for non-medical related business Why is healthcare today so vulnerable to fraud?  One reason is that medicine has become much more complex, and the doctor-patient relationship has changed.  For instance, a patient nowadays might be under the care of multiple providers, and each provider might not have a clear picture of the patient’s plan of care. Another reason the system is vulnerable to fraud relates to constant changes in billing and coverage.  Terms and conditions of reimbursement often change, too, and they’re highly technical and arcane.  Moreover, the urge – whether cultural or economic – for quick fixes creates opportunities for fraud. What’s being done about it? Various public and private-sector anti-fraud organizations have formed.  Through education and working with lawmakers and regulators, they’ve made progress preventing fraud and reducing its cost to the system.  The legal nurse consultant is another resource to which many fraud investigators have turned for the technical knowledge and experience it often takes to spot a fraudulent medical claim. Jordan Ilderton, RN, BSN is a Legal Nurse Consultant with MKC Medical Management.  Contact Jordan at...

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Lies, Fraud, and Medicare Thieves

Posted by on Jun 29, 2012 in Blog, Health Care

When does Medicare fraud happen? Typically, this occurs when a health-care provider knowingly bills Medicare for goods or services that were not provided, or when a person uses someone else’s Medicare information to obtain goods and services they are not entitled to. Some beneficiaries may sell their Medicaid number to others who submit bills for health goods and services that were not provided. Medicare Fraud – Cost of Crime We all know what Medicare fraud is but did you know that recent statistics suggests that Medicare loses more than $60 billion per year because of this white collar crime? That amount of money would pay for almost half of all full-time college students in the country for a two year or four program! These scams are so lucrative they have even surpassed cocaine dealing as the major criminal enterprise in Miami, Florida. Because all scammers take pride in their work, they develop creative ways to pursue their ill-gotten gains, such as ambulance operators making phony trips, a fake pharmacy or medical clinic from a cheap office front, shipping unwanted penis enlargers to diabetes patients and billing for personal expenses such as jewelry, cars and vacations. Consider these behaviors Medicare fraud: Partially filling prescriptions, but charging as if a full prescription was provided. pay day loans instant approvalbest rated payday loans100 dollar loan no credit check Giving or accepting something in addition to normal reimbursement from a patient, other health care provider, or insurer in return for medical services. This is known as a “kick back”. Prescribing medications, drugs, or treatment that are not medically necessary. Charging Medicare or Medicaid patients a higher rate than others for the same prescription. Knowingly providing defective products or services. Falsely diagnosing a more severe ailment than the one the patient actually has. This is known as “upcoding” a diagnosis, thereby justifying a more expensive drug therapy or other treatment than that which the patient’s health requires. Inappropriate changes in patients’ prescriptions from one drug to another as a result of kickbacks or for other improper reasons. Paying beneficiaries with no health problems to make unnecessary visits. Fabricating claims from nonexistent clinics, patients or deceased patients. Changing a diagnosis or treatment code to secure a higher reimbursement. Billing for services not actually performed, known as “phantom billing”. Embezzlement of recipient funds. Billing more than one services that should be combined into one. This is known as “unbundling”.  Fighting Thieves So how do we fight them? Various vendors have developed software for identifying several indicators of fraud. These systems can identify providers who consistently submit questionable claims, it recognizes patterns within individual claims, without reference to the provider, which immediately stops the claim for...

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Obesity Responsible for 10 Percent of Direct Medical Costs in US

Posted by on Dec 7, 2011 in Blog, Health Care

Obesity continues to loom large as a major concern in the US health care arena.  Research shows obesity as responsible for almost 10 percent of direct medical costs in this country. In fact, over 100,000 Americans die each year from complications associated with obesity. With the potential to shorten Americans’ life expectancy for the first time since the Civil War, it represents a true health catastrophe that people swept under the rug for far too long. Obese individuals more likely to become injured  Not only does obesity increase the risk of illnesses, such as prostate cancer, diabetes, breast cancer, stroke, colon cancer, and heart disease; it increases the risk of injury and recovery time from injuries, occurring in car accidents, slips and falls, and others. Obese people are 73 percent more likely to have an accident, resulting in an injury requiring a hospital visit, according to a 2009 study conducted in Australia. The study, conducted by Samsung Life Insurance Lifecare Institute, also indicates that fatigue-inducing sleep disorders, such as sleep apnea and others, exacerbated by obesity, make obese adults more likely to have car accidents. Once injured, obese people spend longer in the hospital and have a higher incidence of complications, including death, than normal-weight individuals. Obesity – almost impossible to treat  Once a person becomes obese, the condition is almost impossible to treat effectively. The key lies in prevention of obesity. While numerous initiatives exist to stem the growth of serious diseases and conditions, such as heart disease and certain cancers, almost none exist that focus on truly preventing obesity. Congress has begun to implement things like junk food taxes and other initiatives, modeled after tobacco legislation that successfully decreased the number of American tobacco users. But these initiatives are problematic in that people don’t need tobacco to live. All people need food to live. Inexpensive, readily available food in urban areas has done much to decrease hunger and starvation among the poor. Promotion of healthy lifestyles – a call to action for all  In addition to the typical community interventions of educating people about healthy food choices, making healthy foods available, promoting exercise, and breast feeding, private industry must get involved as well. Companies should implement health and wellness programs to prevent illness and promote healthy living as part of their benefits package. They should execute a plan to help those who already suffer from obesity, or are clinically overweight, take steps to change the habits and tendencies that led to their condition in the first place. In the world of case management and legal nursing consulting, I see obesity and sedentary lifestyles effecting pre-operative workups, lack of ability to bounce back after a minor injury, increased...

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