Abstract

Objective To model the effect on UK vascular mortality of all adults over 50 years old being prescribed either a statin or an apple a day.

Design Comparative proverb assessment modelling study.

Setting United Kingdom.

Population Adults aged over 50 years.

Intervention Either a statin a day for people not already taking a statin or an apple a day for everyone, assuming 70% compliance and no change in calorie consumption. The modelling used routinely available UK population datasets; parameters describing the relations between statins, apples, and health were derived from meta-analyses.

Main outcome measure Mortality due to vascular disease.

Results The estimated annual reduction in deaths from vascular disease of a statin a day, assuming 70% compliance and a reduction in vascular mortality of 12% (95% confidence interval 9% to 16%) per 1.0 mmol/L reduction in low density lipoprotein cholesterol, is 9400 (7000 to 12 500). The equivalent reduction from an apple a day, modelled using the PRIME model (assuming an apple weighs 100 g and that overall calorie consumption remains constant) is 8500 (95% credible interval 6200 to 10 800).

Conclusions Both nutritional and pharmaceutical approaches to the prevention of vascular disease may have the potential to reduce UK mortality significantly. With similar reductions in mortality, a 150 year old health promotion message is able to match modern medicine and is likely to have fewer side effects.

I.C. System, a family-owned accounts receivable management firm, recently launched a new chiropractor debt collection website highlighting the company’s 40+ years of chiropractic collection experience and industry expertise.

Following our release of the fee schedule increase for Medicare codes 98940,-41 and -42 there seemed to be some disappointment in the overall results. While we all acknowledge that the most commonly used code, 98940 (thanks to Medicare audits), had the lowest percentage increase, the implicates can have far reaching impact as other carriers look to the RVU that Medicare sets. In addition, the ACA Medicare Carrier Advisory Committee and executives of the ACA have been diligently meeting the CMS and HHS to get us full scope coverage to include E & M codes as well as active and passive modalities. Unfortunately, as we know just from our dealings in NY that major changes take time. In the interim, a 2% increase in 98940 is better than another decrease, and as we draw closer to paying off the 2% reduction due to the overage of the demonstration project (thanks to some of our colleagues in part of Chicago), that decrease is anticipated to be lowered in the coming year.

For further information on the efforts of the ACA, please check out the following links:

• ACA Responds to Joint Congressional Discussion Draft on Medicare Physician Payment Reform (Nov 2013) 
• ACA RUC Advisors Comment to CMS on DCs Billing for Evaluation & Management (E/M) Services 
• ACAtoday.org Medicare Advocacy 

Respectfully submitted,
Mariangela Penna, DC
NY CAC Representative

When your staff has been unsuccessful in reaching a patient who is past due on his or her account, the pressure is on you to have “The Talk” before you send them to chiropractic debt collection help. As much as it pains you to do it, you must. However, your interaction doesn’t have to be miserable. In fact, if done correctly, it may even prove to be quite fruitful!

Here are 10 Key “Do’s” and “Don’ts” to familiarize yourself with before you approach your patients:

1. Do be a soft place to land – Most people are embarrassed in discussing financial troubles, so it is vital to provide a welcoming situation where they will discuss the situation with you. When approaching a patient who has a delinquent account, try phrasing your initial question something like this: “[Patient Name], I noticed that you’ve gotten behind on your bill, and was just curious – is everything okay? Is there some way I can help you?”
2. Do be genuine – A facade can be spotted a mile away. If you come across as only wanting their money and don’t show that you still care about them as a person and as a patient, then they will tune you out immediately. From a patient’s point of view, if you don’t care about me, why should I care about you and pay my debt?
3. Do give them the benefit of the doubt – This is vital! Be intentional in believing that your patient will pay his or her bill. It has been proven that your beliefs do_dont2will determine your actions, especially unconscious facial expressions and mannerisms. If you believe that the patient is never going to pay up no matter what you say or do, then it will inevitably slip out in one way or another.
4. Do be upfront and clear – If your patient is unmoved by your attempts to reach a financial agreement, ensure (verbally) that he or she knows the bill will be sent to chiropractic debt recovery as part of the process.
5. Do have them sign a letter of advice. To confirm what you have stated above, have your patient sign a document affirming that you advised him or her that the account will be handled by chiropractic debt collection help if he or she is unable to pay. Remember to give your patient a copy.
6. Don’t make it personal – Since this is your business, you may have the tendency to take things personally when people fall behind on their financial obligations. Don’t! Business is business, and those that survive the emotional turmoil and refuse to get personally attached to these types of situations will always come out on top.
7. Don’t take a knee-jerk approach – Remember that people generally have good reasons for letting their account fall behind. Find out why they are not paying their bill – You may be surprised by what you learn!
8. Don’t scare anyone away – Being non-confrontational is key. Most people avoid uncomfortable situations like the plague, and certainly you don’t want to create a rift in your doctor-patient relationship. If people get spooked, they won’t come back.
9. Don’t forget that this person is still your patient. The person you’re dealing with has a history with you and is still a potential source for referrals. The way that you handle this situation can determine if he or she lambasts you on Facebook or refers all his/her friends and family to you instead!
10. Don’t lose hope – Not only can a delinquent account easily – and quickly – become a current account, but there’s still a good chance you’ll get your money even if patients don’t respond to your efforts. Send the account to your chiropractic debt collection agency and let them worry about it!

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IC System Quick Facts

• For more than 40 years, Chiro Collect, Powered by I.C. System, has worked with hundreds of Chiropractic Practices nationwide, collecting millions of dollars on their behalf. I.C. System is a BBB Accredited Business with an A+ Rating.
• We are among just a few dozen agencies worldwide to be ”certified” for Best Practices through ACA International, The Association of Credit and Collection Professionals, Professional Practices Management System (PPMS) program.
• We leverage comprehensive skip-tracing efforts to find “missing” patients.
• We offer Chiropractor Clients Online Tools to easily submit debts, view our work effort (number of letters mailed, number of calls made, etc.) on debts, report payments, and generate reports.

See more at: http://chirocollect.com/

Sometimes, doctors wonder if utilizing chiropractic debt collection services are worth the time and money. Unlike other independent health care practitioners, chiropractors generally do not deal with massive delinquent debt loads because their services are traditionally affordable. Typically, the average debt chiropractic patients accrue is around $250.

You may be asking:

• Is it worth my time and money?
• Will this burn bridges with current patients and potential referrers?
• What are a couple hundred bucks in the grand scheme of things?

• Due diligence – Have you given your patients a fair opportunity to respond? Typically, the best practice to collect from an unresponsive patient is to leave two voicemail messages and send one (final) written notification concerning a delinquent account. After two weeks with no response, the assumption is that your patient is avoiding the situation and you are best served by utilizing a chiropractic debt collection agency.
• Count the cost – The debt has to be worth your investment. Discuss your situation with a certified chiropractic debt recovery professional to see if utilizing their services makes sense for your bottom line.
• Is this a new or perpetual problem? – If this is a first-time offense with a long-standing patient, then think twice about sending him or her to a chiropractic debt collection company prematurely. People usually have a good reason for falling behind, and this is especially true with patients who have proven their loyalty and timely payment ability in the past. On the other hand, if this is a new patient and you suspect that he or she may be predatory, then having a no-nonsense approach will probably serve you well.
• Was it your fault? If you didn’t set the tone, neglected to deliver proper expectations up front or were lackadaisical in your fee-for-service procedures, then can you really fault your patient for falling behind? In this situation, to save your reputation and credibility, use chiropractic debt collection help only after fully addressing the situation with your patient and giving him or her ample time to respond.

Chiropractor examining a charming woman's backDepartment Chair at Life University Lydia Dever tells the story of a situation in which a patient fell behind on a considerable amount of money and then just disappeared. Giving her the benefit of the doubt because this patient was a loyal patient in the past and didn’t seem too malicious in her actions, Dr. Dever forgave the debt and forgot all about it. Two years later, completely out of the blue, the patient came into the office and handed her a check for $300. She thanked Dr. Dever for her understanding and told her a touching story as to why she wasn’t able to pay. Evidently, the patient was so embarrassed that her bill got behind that she avoided the office, but after her account got current she resumed care. Does this sound like a referral source or what?

Of course, not every story ends with such a happy feeling, and you will be required to utilize chiropractor debt collection services at one point or another. This is particularly true for doctors who specialize in personal injury and high profile insurance claims. Thankfully, chiropractor debt recovery options are readily available to help in these situations so that you can focus on what you do best.

Thankfully, many chiropractors are inexperienced in dealing with chiropractic debt collection agencies because a large number have cash practices and keep costs affordable so that their patients are able to pay on time. At the same time, however, ignorance is not bliss when you discover that several patients are falling behind on their payments. If this happens to you, follow these tips to ensure that your experience is positive and financially advantageous!

Keeping an eye out for red flags

Although, in a perfect world, all chiropractic debt collection agencies are regulated, you still want to make sure that you’re dealing with a reputable agency. Do your research online and make sure that they are the type of debt collection agency that you want representing you and your practice.

• Certifications –Your chiro debt collection agency should require that their collectors be certified, for example, through industry trade groups such as ACA International – the Association of Credit and Collection Professionals. This ensures you’re going to partner with an agency that has a vested interest in finding and training high-quality collectors.
• Compliance – Make sure that the collection agency is fully compliant with the Fair Debt Collections Practices Act (FDCPA) and is licensed in all states where your patients live and where you run your practice.
• Data Security – Every reputable chiropractic debt collection agency will have emergency backup systems in place and will maintain strict privacy measures so that your data is not only secure, but will be used for business related purposes only.
• 24/7 Online Access – This is more of a convenience than a hard, fast rule. Being able to submit and access the status of your files at any time of the day is a standard in today’s Internet economy and will weed out the companies whose systems may be outdated.

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IC System Quick Facts

• For more than 40 years, Chiro Collect, Powered by I.C. System, has worked with hundreds of Chiropractic Practices nationwide, collecting millions of dollars on their behalf. I.C. System is a BBB Accredited Business with an A+ Rating.
• We are among just a few dozen agencies worldwide to be ”certified” for Best Practices through ACA International, The Association of Credit and Collection Professionals, Professional Practices Management System (PPMS) program.
• We leverage comprehensive skip-tracing efforts to find “missing” patients.
• We offer Chiropractor Clients Online Tools to easily submit debts, view our work effort (number of letters mailed, number of calls made, etc.) on debts, report payments, and generate reports.

See more at: http://chirocollect.com/

Nothing like stating the obvious, but the most effective way to keep your accounts from requiring professional chiropractor debt collection services is to prevent them from going delinquent in the first place! Easier said than done, right?

According to Life University Chiropractic Sciences Department Chair Lydia Dever, the key is to be proactive and not reactive. Owning and operating a private practice for the past decade, Dr. Dever has utilized chiropractor debt collection help only once in her career. “You need to make sure your patients pay every time they come into the office,” Dr. Dever says. “That way things don’t get out of control.”

Dr. Dever makes a good point. This is business, not charity. To keep your books up-to-date, you must assure that your patients pay their office visit fees before they leave every time. Being an industry deeply rooted in service, chiropractors are notorious for not being firm in this area. Subsequently, many doctors get taken advantage of, but this happens needlessly.

5 Steps to Ensure Payment

Of course, you can’t force anyone to do anything. When your patient attempts to laugh off their bill by saying, “Get ya next time,” simply don’t do it. Instead, employ these methods:

1. Transparency – Be upfront with your office fees and payment policies on Day 1 before you begin care. Over-communicate so you don’t miscommunicate. This way, everyone is on the same page before care begins, and patients understand that their account will be sent to chiropractic debt collections if they fall behind.
2. Staff support – Train your staff to be firm, but polite, in regards to settling an account before a patient leaves your office. Staff members are your gatekeepers and set the tone for your office. If they are no-nonsense about finances, your patients will respond accordingly.
3. Do not bill – Although some patients will request for you to send them a bill, don’t do it. If they forgot their wallet and have no way to pay, then (firmly, but politely) let them know that payment remittance is expected by the time of their next visit. If they try to pull the same thing next time, nip it in the bud right away. This person could be a predatory patient, and you don’t want him or her in your practice.
4. Be the authority – It may be easy to pawn off the “enforcer” role to your CA, but you are the doctor and it is your practice. Step up when needed and discuss with the situation with your patient next time he or she is in the office.
5. Having “The Talk” – First of all, be non-confrontational and gracious. Remember that people are innocent until proven guilty, right? People steer away from confrontation and you may lose them as a patient if you come off too strong. Your patients will generally have good reasons for what they do, so ask them why they didn’t pay their bill. For instance, you may end up learning that they are in dire financial straights and that they are willing to sign on to a payment plan.

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IC System Quick Facts

• For more than 40 years, Chiro Collect, Powered by I.C. System, has worked with hundreds of Chiropractic Practices nationwide, collecting millions of dollars on their behalf. I.C. System is a BBB Accredited Business with an A+ Rating.
• We are among just a few dozen agencies worldwide to be ”certified” for Best Practices through ACA International, The Association of Credit and Collection Professionals, Professional Practices Management System (PPMS) program.
• We leverage comprehensive skip-tracing efforts to find “missing” patients.
• We offer Chiropractor Clients Online Tools to easily submit debts, view our work effort (number of letters mailed, number of calls made, etc.) on debts, report payments, and generate reports.

See more at: http://chirocollect.com/

With the onset of increased premiums and decreased coverage for beneficiaries along with diminishing reimbursements for health care providers, many financial experts are speculating that America is currently formulating a health care bubble. Having the potential to burst, similar to the housing bubble that caused the 2008 recession, it is imperative to have processes in place so that you and your practice will be sheltered. In essence, that is exactly what a chiropractic debt service agency does for you. It shelters you in the storm and helps ensure that your bottom line is not affected, regardless of the economy.

State of the Union
According to ACA International, The Association of Credit and Collection Professionals, “An estimated 48 million people were paying off medical debt in 2012, up from 44 million in 2010 and 37 million in 2005.” In addition, 75 million Americans reported that they experienced difficulties paying off healthcare-related expenses in 2012. Currently, 50 million Americans don’t have health insurance and, according to Ernest & Young, “Healthcare-related debt is the leading category of debt collection among survey respondents, accounting for more than half of all debt collected in the industry.”

Role of ObamaCare
The Affordable Care Act (popularly referred to as “ObamaCare”) only mentions “chiropractic” three times in the entire 2,407-page text. This can be interpreted in two different ways: With prevention being one of the underlying focuses of the entire document, some experts understand this to mean that chiropractic services – specifically asymptomatic, “wellness care” – will be covered to a greater degree than most insurance companies do now because it epitomizes preventative medicine. Other experts, however, fear that the language is too scant to properly define how chiropractic services will be covered.

In essence, the verbiage is such that the government can change their perspective on chiropractic care and services as ObamaCare progresses, thereby providing chiropractors little security in the future health care model. Consequently, the role of fee-for-service and chiropractic debt collections will greatly determine your financial bottom line as you manage co-pays and deductibles or conform to a non-insurance dependent cash model.

Helping stabilize the economy
The data presented by Ernest & Young depicts the vital role chiropractic debt collection agencies and others play in curbing the ubiquitous debt load that is affecting unsheltered healthcare professionals nationwide:

• Total debt collected in 2010: $54.9 billion.
• Total debts that were returned to creditors and health care professionals: $44.6 billion.
• “Early out debt” collected (receivables aged 90 days or less): 30 percent.
• “Bad debt” collected (receivables aged 90 days or more): 70 percent.

As consumers continue to struggle paying their bills, chiropractic debt collection agencies and others like them are becoming the backbone of our economy. This is particularly true as out-of-pocket health care expenses skyrocket and government-funded insurance companies continue to cut coverage.

Securing your future
Whether your chiro practice has suffered the fi nancial consequences of delinquent debts or not, take time today and secure your future by working with an agency that specializes in chiropractic debt collections.

Some tips to consider:

1. Be proactive. No one knows which patient will fall behind on their fi nancial responsibilities and when. By establishing a relationship with a chiropractic debt collection agency today, you won’t be scrambling for help when you need it most.
2. Be encouraged. The fate of your offi ce’s balance sheet is not sealed because you serve in an area that has been hit hard economically. Time-tested, proven collection processes and approaches ensure that your fi nancial needs can be met by the right chiropractic debt collection agency.
3. Saving face. Make sure you choose a collection agency that will not only recover your lost funds, but will also make sure your professional and personal reputation remains positive.
4. It’s never too late. Don’t give up! The data from Ernest & Young’s report is quite telling and encouraging for any chiropractor who is struggling with long-term past due accounts. Relinquish the burden and watch your P & L soar!
5. Find someone who understands. We can’t emphasize this enough: Make sure you partner with a collection agency that understands your business model, your patient base and your profession!

As you work toward stabilizing your practice in a troubled economy, it’s important to understand that chiropractic debt collection agencies can help mitigate the fi nancial risks associated with providing healthcare. In an effort to maintain your energy on what you do best, leave the stress of collecting your debts to devoted professionals! Once the burden is lifted off of your shoulders, you and your staff will be free to focus on what will bring you future success without having to worry about past due accounts!

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IC System Quick Facts

• For more than 40 years, Chiro Collect, Powered by I.C. System, has worked with hundreds of Chiropractic Practices nationwide, collecting millions of dollars on their behalf. I.C. System is a BBB Accredited Business with an A+ Rating.
• We are among just a few dozen agencies worldwide to be ”certified” for Best Practices through ACA International, The Association of Credit and Collection Professionals, Professional Practices Management System (PPMS) program.
• We leverage comprehensive skip-tracing efforts to find “missing” patients.
• We offer Chiropractor Clients Online Tools to easily submit debts, view our work effort (number of letters mailed, number of calls made, etc.) on debts, report payments, and generate reports.

See more at: http://chirocollect.com/

A New Jersey federal judge has ruled that a doctor of chiropractic (DC) may pursue his overpayment allegations against UnitedHealthcare (United) even though his patients are no longer insured by the company. The ruling says patients are still subject to the health insurer's overpayment recoupment procedures.

United stands accused of retroactively reducing the amount of money owed to doctors of chiropractic as reimbursement for their incurred expenses. The litigation, filed on Jan. 24, 2011, represents a nationwide class of health care providers who were subjected to United's improper recoupment of payments for services provided to United subscribers. ACA joined the lawsuit in April 2011 when it added a host of injurious practices perpetrated upon practitioners by Optum, United's subsidiary.

Learn more about ACA's insurance advocacy work in the Chiropractic Network Action Center, www.acatoday.org/CNAC, which provides helpful resources and the latest information regarding network concerns for providers and their patients.

As per the recent ACA press release, thanks to the longstanding and ongoing efforts of the ACA effective 1/1/2014 there will be an increase in the RVU for CMT codes in the Medicare fee for service system. The increase amounts to slightly over 2% for code 98940, 9% for 98941 and 10% for 98942. As we know many other systems look to Medicare as their fee schedule base, theses increases may have far reaching impact. In addition there will be upcoming decreases in the fee reduction penalties due to the expenditures from the demonstration project. However please be advised that there is still a 20% reduction pending if the SGR remains in place. Although every year Congress acts at the last minute to repeal the SGR one never knows and a last minute grass roots effort may be necessary to hold off this reduction. Watch your emails for how you can help!

PQRS

It still isn’t too late to start for 2013, start now and you can avoid penalties in 2015! There will be some changes for 2014 and we will get those out to you as soon as they are available. Don’t wait start reporting appropriate G codes today. Visit www.acatoday.org and search PQRS2-13 toolkit for details.

Railroad Medicare Update

The ACA continues to dialogue with administrators from Palmetto GBA regarding their blanket denials and excessive documentation requirements. CMS prefers that this gets handled between Palmetto and the ACA but will step in if necessary. If you receive a denial on Railroad Medicare please appeal, it will be important if CMS has to intervene.

2014 Medicare Deductible

The Medicare deductible for 2014 is $147, unchanged from 2013. Medicare Part C (Advantage Plans) copayment for chiropractic services cannot exceed $20 or 50% in the case of co-insurance. If you have evidence of non-compliance with this please send it to the ACA. If patient is in a Part C plan that does not have a chiropractic panel and there is no out of network benefit you may charge the patient the appropriate Medicare limiting charge and are exempt from sending a claim.

Proper Use of an ABN Form

There is NO OPTING OUT of Medicare, you may be participating (accept assignment) or not. If you choose to not obtain a Medicare provider number you CANNOT see Medicare patients, the choice is yours. Having them sign an ABN on the first visit, declaring them maintenance with instruction to select Option 2 is not appropriate. As this is becoming a trend in some states with some groups many state boards are looking into this to sanction doctors.

For a properly delivered ABN, whether the patient selects Option 1 or 2 you may collect your full fee without Medicare fee restrictions. If the patient selects Option 1 submit the bill to Medicare, if Option 2 is selected a bill is not submitted.

CERT Reviews

Changes being made to CERT reviews, the time frame to respond was 75 days with 4 reminders by letter. Effective 1/1/2014 CERT review timeframe response has been shortened to 60 days with the initial letter Day 1 and reminders Days 30 and 45. As with all audits, read the letter carefully and send documentation as required by the letter, for assistance and guidance visit the ACA website at www.acatoday.org/Medicare.

Respectfully submitted,

Mariangela Penna, DC
NY CAC Representative

An article in the Medicare MLN Matters from National Government Services on April 9, 2013 indicated that the restriction of chiropractors referring to radiologists as the ordering physician on Medicare beneficiary x-rays was changed. An inquiry was sent to the ACA regarding this policy change.

According to the ACA Medicare committee, research into the MLN Provider Bulletin on April 9, 2013 indicates that the article is incorrect. The reference cited in the article related to the ordering of diagnostic tests did state there was a change. HOWEVER, the ACA checked the Code of Federal Regulations, which are current as of October 28, 2013, and the citation related to the Chiropractic Exception (42 CFR 410.32(a)(1)) has been REMOVED. We recommend that you do not use the radiologist as the ordering physician until the ACA confirms the changes. The ACA is following up with CMS for further clarification and will keep us posted.