AVOID POST-PAYMENT AUDITS Stop crying & play ball!


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image Man Holding a basketball AVOID POST-PAYMENT AUDITS
Stop crying & play ball!
By Ted A. Arkfeld, DC

Several years ago, a three-on-three basketball tournament in Phoenix was themed “Quit Hacking; Stop Crying; and Play Ball.”

That phrase is good advice for chiropractors who complain about unfair chart-review determinations by insurance companies.

Some practitioners have a legitimate gripe, but, overall, the profession can, and must, do a better job in documentation. Poor documentation causes chart-review decisions and increases the chance of being investigated for fraud or abuse.

A 2005 report by the Office of the Inspector General (OIG) was highly critical of chiropractic documentation. The report concluded that 67 percent of Medicare claims examined as part of the study contained documentation errors or omissions that failed to validate duration, frequency, or reasons for the treatment rendered — resulting in erroneous payments of a staggering $280 million by Medicare.

The OIG report also showed the federal government is getting serious about healthcare fraud and abuse, and thanks to the National Provider Identifier (NPI) program, it will become easier for the government and insurers to identify abuse and fraud.

The NPI program, which requires all healthcare providers to register, will enable the collection of data on every healthcare provider in the United States. And that information will be used, in part, to establish profiles.

Some insurers are already using profiling. In the near future, this will be common practice for all insurance companies.

Some chiropractors are frightened about profiling; some are angry. Most think profiling will have no impact on their practices. Be assured, however, that profiling should concern practitioners who rely on reimbursements because any practice falling within the parameters of a profile is at risk of having post-payment audits conducted. These audits recoup “mistakes” in payment, as well as find cases of fraud and abuse.

Post-payment auditing is the method for the Medicare system and private insurance companies to recoup monies paid out for services rendered that are not medically necessary, such as maintenance treatment. All practices, regardless of size or location, will be subject to potential post-payment audits.

Auditing can also find cases of fraud and abuse.

A fine line exists between fraud and abuse. Fraud occurs when an individual intentionally represents information to be true when he or she knows it to be false (or does not believe to be true), and the misrepresentation could result in some unauthorized benefit to the individual or some other person.
The most frequent kind of fraud arises from a false statement or misrepresentation to a federal entitlement program, such as Medicare. Fraud can, and does, occur with respect to private insurance companies as well, however.

Under the broad definition of fraud are other types of violations, including:

Offering or accepting kickbacks;
Routinely waivering co-payments; and
Fraudulently coding, including unbundling, undercoding, and upcoding.

Abuse is a term associated with providers whose medical, business, or fiscal practices fall outside accepted parameters. These are providers whose services are not considered medically necessary or whose services or procedures are not consistent with professional standards. Or, they are providers who request improper reimbursement or overuse specific treatments or codes.

The difference between fraud and abuse lies in knowledge and intent: Providers cross the line from abuse to fraud once they become aware their practices are considered abusive, yet they continue. At that time, their activities become fraudulent.

If you undergo a post-payment audit, you bear the burden to exonerate yourself. Auditors assume you should have known certain practices were not only abusive, but on some level fraudulent.

If the audit results in an unfavorable result for you, you will be paying money back to the insurer.

It is time to quit hacking, stop crying, and play ball.

Protect yourself from an audit

To protect your practice and livelihood, assess your documentation procedures. Ask yourself (and your staff):

1. “Would my documentation survive an audit?” It would, provided your initial and re-evaluation examination reports meet or exceed the criteria for E/M (evaluation and management) codes. Surviving an audit also requires clear, concise notations that show medical necessity for the treatment being rendered.

2. “Are we coding and billing appropriately?” The answer is “yes” if your documentation validates and corroborates the codes being utilized.

3. “Do we have a compliance program in effect for our office?” A compliance program should include a “zero tolerance to fraud” form every staff member reads and signs; periodic staff meetings to review HIPAA requirements; and a written policy and procedure concerning what to do if fraud and abuse are suspected in the office.

4. “Do we have a compliance officer for our office?” This person is responsible for all HIPAA training in the office and monitoring all billing and coding procedures. He or she is also the “go-to person” when questions arise regarding potential abuse and fraud issues.

5. “Do we do internal audits?” Your compliance officer should schedule quarterly internal audits to ensure correct billing, coding, and documentation are taking place in your office.

Ted A. Arkfeld, DC, MS, CICE, DABFE, CPC, is the president of Advanced Compliance Technologies, PLLC — a consulting firm located in Gaylord, Mich., specializing in compliance programs, billing and coding, and proper documentation. He can be reached by phone at 989-614-0261 or by e-mail at drarkfeld@hotmail.com.

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