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Daniel: Hello everybody. Welcome to the Tuesday Webinars series Chiropractic Economics Webinar for doctors of Chiropractic. I’m Daniel Sosnoski, Editor in Chief of Chiropractic Economics. Today’s webinar, Audit Proofing your Practice, is sponsored by Infinedi and as always our program is being recorded and will be archived at Chiropractic economics website. www.chiroeco.com/webinars for one year. Our experts are on board here today to speak with you. And when their presentation is complete, we will follow with a question and answer period. You can submit questions throughout the presentation by clicking on the appropriate icon on the right side of your screen. We’ll do our very best to get to all of your questions but if we run out of time we’ll forward the remaining questions to our experts and notify you via e-mail when the answers are posted on our website chiroeco.com/webinars. Our presenters today are Brad Cost, the president and CEO of Infinedi, Kim Driggers, General Counsel for the Florida Chiropractic Association and Director of Business Development for SecureCare Corporation and Bharon Hoag, Executive Director of OneChiropractic, who are here to help you learn how to protect your practice against being audited by following best practices and compliance and preparing the right documentation. Brad, Kim and Bharon thank you for taking the time to participate in our webinar, and for sharing your expertise with healthcare compliance and helping our audience understand how they can best position their practices. Before we get started, Bharon, could you please give us a brief background on yourself and your work with practice compliance?
Bharon: Yeah sure, well I’ve been in the industry I’m just now celebrating my 20th year in the Chiropractic industry. And my history has taken me everywhere from being a CA to owning multiple Chiropractic offices in Ohio and throughout the country and then I was also one of the very first Certified Professional Coders and Certified in Healthcare Compliance in the Industry back in the early 2000 and so I’ve consulted and audited work with many payers. I have been at the highest level of Medicare communicating and figuring out this whole issue of how to tell the Chiropractic story in a language that other people understand. So definitely passionate about this topic I’ve been around the industry for a number of years, teaching and training. But kind of my niche is to not scare you from an idea of compliance but empower you on how to make sure you’re telling a story and then you just also happen to be compliant. So it’s a different approach to why your documenting, why you are communicating the story of Chiropractic and it’s not out of fear, but it’s out of empowerment to be able to communicate the message of Chiropractic.
So it’s really when it comes down to it for chiropractors and I’m excited about this panel because as we talk with Kim and ask Brad and they communicate it from the analytic side and from the legal side. I wanna start off this presentation helping the listeners understand that this is not as complicated as it’s become. And if you look on the screen you kind of see the scales of justice if you will. When our profession originally started, we’re 122 years old as a profession. And probably all the way up until the mid-80s, our whole focus was communicating the message of Chiropractic. That’s really all we put our time and energy in and we did a really good job of that, I mean we definitely had some hard times, I think we went through our own civil rights movement if you will in the late 70s, where chiropractors were imprisoned and they were threatened and we had all these different issues that had happened.
I’ve had a privilege myself of meeting a number of those people before they had passed and those that are still alive today as Ohio had probably more imprisoned Chiropractors than any other state. And if you can see the passion that was in those people and the commitment that they had to make sure the world understood what Chiropractic was. Well, you get us to the mid-80s and that’s when you start to realize that our focus shifted, we call them the Mercedes 80s. These are the days that we literally got paid for almost breathing in the presence of a patient. I mean, there was no issues, they paid us for what we did they paid a very well. We were using E&M codes just like the MDs were using and there was relatively no brain damage to communicate and to work with the insurance companies. But as we moved into the early 90s to mid-90s a shift happened and managed care came in. At that point our profession literally got cut in half when it comes to reimbursement, you were seeing as many patients, if not more than you were before but you’re making half the money. And that’s when the shift happened and this is why we are sitting where we are today. Our entire focus went from telling the story of Chiropractic and it drove to reimbursement. Perfect example is Medicare with the modifiers, I mean, when they introduce the 18 modifier after 2004, literally no one knew what the modifier meant but they knew that if they put it on the code that that meant they got paid. So chiropractors started doing whatever anyone told them to do to get paid, and we started playing games. We went away from standing our ground and telling our story and paving our message through the health care system and it started being this big game. Oh you want this diagnosis to get paid? Okay, I’ll do that diagnosis. And over time what has happened is they painted us into this box through our managed care contract through the provider agreement contract that we signed and it says that, “We can only do this diagnosis or we can only do those codes.”
And then over time what’s happened is chiropractors have tried to find different ways to diversify their revenue. So we’re adding a new services, maybe we’re adding more time on to care plan because we need to see more visits in order to maintain a certain volume. So it’s important to understand how we got to the point where we are now. And then the last decade has really been about this term called “compliance” and you have HIPPA and you have the “meaningful use” and you have all these things that come in that literally the chiropractors’ job now is literally to go to work and try to be compliant. And all of our passion, all of our purpose has steered away from the treating of the patient and its fallen onto making sure that we don’t end up in prison or paying millions of dollars back to the insurance companies or the government. And that is our problem, so I’m gonna challenge you guys if you listen to the rest of this call today, I want you to understand that this is not about being compliant. And although Kim, Brad and I are really trying to empower you guys to understand what it means to not do things that make you more visible within an audit, I also want you to understand your focus and it’s got to stop being on reimbursement, it’s got to stop being on trying to attempt to be compliant and it got to start being on you know what, I’m gonna tell my story. I know the care that I’m providing that’s necessary, I know the patients that are receiving my care are benefiting, that it’s fair exchange in what I’m doing and I’m also okay to communicate that story to the point where I’m not gonna let them tell me who I am and what I get to do.
And I understand that you know there’s a bit of an arrogance in that stand but I think it’s about time that our profession comes together, and works together to tell a story. And all the field that I’ve been in and all of the meeting that I’ve been in, all the way with medical directors with Medicare to owners of insurance companies, they all boil down and say if we just understood what chiropractors were doing and why they were doing it, there wouldn’t be an issue. This falls to things like treatment plans, falls to things like proper diagnosing. I used to teach when I was doing diagnosing that just because the claim for back in the day only had four boxes that doesn’t mean that there’s only four possible conditions that your… Your job is to communicate the story of what you’re doing.
And if you put your effort and energy into communicating the story then you’re gonna find that becoming compliant is actually very easy, because the story in and out of itself is going to meet all of the requirement that you need in order to tell the story, or to be compliant. And this is what we have to do is shift our perspective and our focus to why we do short notes, why are we taking the initial history? Why do we create a treatment plan? It’s not to be “compliant”, it’s so that we can communicate that we know how to evaluate and manage a patient and that the care we’re providing we understand that there’s a beginning and an end to the active phase. We understand there’s a beginning and an end to the strengthening and stabilization phase, and we understand there’s a beginning and an end to our maintenance phase. Now, your philosophy is gonna determine where you’re at in those phases, but the average chiropractor, it’s almost like you take a bunch of dung and you throw it on the wall just to see what sticks. Because there’s no management to the patient, it’s just treatment, treatment, treatment, treatment.
So as you listen to Kim as she goes into this next section, I want you to understand it’s about communicating a story. As she lays out kind of all the pothole that exist within the chiropractic community when it comes to pay or audit. And then when Brad talks to you about the data and how the analytic actually help you better see the story you’re telling, I want the root of all of that not to be that you’re trying to be compliant, but that you’re trying to make sure you’re conveying the appropriate story of what’s going on with your patient. You know I ask this question a lot when I do live events and I say, “How many of you would love it if I could literally snap my fingers and all you ever have to worry about is just providing treatment to your patient?” And obviously everyone’s hand goes up, but I need you to understand you don’t have that luxury. You have chosen a profession whether you meant to or not that you’re running a business, and in that business there are people that want certain things in order to support why they’re paying. And it doesn’t need to be difficult, it doesn’t need to be this whole ostentatious process, it can be a very simple process that’s based on just telling the story of chiropractic and how you’re managing your patient and you’re gonna be just fine. So my challenge to you throughout the rest of this webinar and possibly any other webinar you watch that’s talking on compliance and coding and documentation, boil it down to its root level and just tell the story of chiropractic.
People, I’m telling you, next to the Gospel there’s not a better story in the world. And if we tell it authentically, unhinged, you’re gonna find that you’re gonna be, you’re gonna find more joy in the patients that you have seen and you’re gonna have more of a desire to go out into our world and tell our story you’ll attract more people to you. Don’t let compliance, audit and all of those things suck the joy out of who you are. You love what I love and that makes me love you for what you’re doing and I wanna make sure that you have people around you that are empowering you to tell the story, empowering you to not be fearful of things you can’t control and know that you have a support system around you. Should you ever get tagged to wanna be looked at, there are a lot of great people out there that wanna hold your hand through that process and make sure that you continue to have the joy you need to have in treating your patients. So I’m excited to hear the rest of this webinar, and for Kim to explain to you kind of some of those potholes and then Brad’s gonna wrap it up and give you a little bit of the analytics and where the data starts to help us tell a story across the entire platform of insurance. So I wish you God’s grace in your life and in your practice and keep loving and serving people, it’s worth it.
Daniel: Okay, thank you very much Bharon. And now Kim would you like to briefly introduce yourself?
Kim: Sure, thank you. Kim Driggers, I am the General Counsel for the Florida Chiropractic Association, I’ve been with them for about seven years now. And I am also the Director of Business Development for SecureCare Corp which is an IPA the FCA in SecureCare in Nebraska created about two years ago to better the landscape of reimbursements in our state and to try and turn things around a little bit. My legal practice started on the defense side in representing auto insurance companies and homeowners’ insurance companies and then turning about six years later on to the other side where I represented chiropractors and patients and medical doctors in first party insurance claims. So that’s really my experience, I’ve had Medicare experience through the FDA obviously, it’s a big fear with a lot of our members here in Florida. We get calls on and frequently calls on. I’ve got a request for an audit, what do I do? So I am looking forward to speaking to you a little bit on it just a general overview, I don’t have all that much time today, and questions will be held to the end.
So first slide, Brad if you would, you’ve got the control, the next one I’m sorry it’s slide 2. Health care fraud is a serious [inaudible 00:12:20] here across the country. The numbers are a little bit older OIG is under there, they’ve just issued in 2015 another work report, but basically in 2011 and 2012 Medicare allowed approximately 1.4 billion dollars of payment for Chiropractic services to Medicare beneficiaries nationwide. And then in 2006, and that’s the numbers that they are using they go back. OIG, their last biggest review found an estimated 178 million out of the $466 million reviewed for Chiropractic services were medically unnecessary. So from then they started doing their audit requests as probably all of you on the phone know Medicare paid for only three chiropractic codes. 98940 one to two region, 98941, 98942. The Medicare Act states that “No payment will be given for services that aren’t reasonable and necessary for the diagnosis of a treatment or injury”. And that it will only pay if the subluxation has resulted in your muscular skeletal condition for which manual manipulation is appropriate treatment.
So the manual states they don’t pay for maintenance therapy, it’s considered medically unnecessary. The chiropractic manipulation must have a direct therapeutic relationship to the patient’s condition, the patient must have a subluxation of the spine and the chiropractor should be afforded the opportunity to affect the improvement of the condition within a reasonable and generally predictable period of time. That’s some of the lingo that is used by the claim adjusters who are on the audit. If you can skip the next slide and go to, keep going one more page, okay. So why do you get requests for an audit? There are several reasons, the one’s considering fraud which are few and far between are for billing for service that you did not render, the big one is for billing what they would say billing for services that aren’t medically necessary, or performed by an unqualified employee. Billing separately for services that are already in a global fee. Now if you can go back throughout the slide, back one slide, okay. Let me talk about one case example and many of you may have already heard of it, read about it and it was out of Kansas and it resulted in a recommended fine of over $700,000 from an OIG report of May 2015, and it is currently on appeal. The clinic is called advanced chiropractic services and they had three offices in Kansas. So OIG asked for an audit, they request 105 chiropractic service line items. They could request 105 samples. OIG went through, they hired an auditor and that auditor found that 98% of the services provided by this clinic were billed at the code 98942. So 98% of the services the same code 98942, the highest was five regions. Pretty surprisingly in this particular case OIG found that none, not one of those 105 entry codes were medically necessary. So of the 105 they found that, $3529 was sealed, was not allowable. What they did though is that they went back and took the sampling of all of their codes that were submitted to Medicare, and found $737,000 were claims made in overpayment by Medicare. But the rules only allow for a three year claims recovery period.
So the recommendation was that the clinic return to Medicare $369,000 worth of what they called medically unnecessary payments. So what the auditor found was that the clinic did not have adequate policies and procedures in place to ensure the medical necessity of those services billed to Medicare. The defense lawyer for ATS went through immediately when the matter was taking place and re-did their policies and procedures so they started immediately instituting new documentation procedures. The auditor also found that none, none of the 105 medical records for those services contained the necessary documentation needed, and 100% of those services they felt were medically necessary. So I mean it seems to me to be an extreme example but it is one example that has hit the books and it’s probably going to be used in this next OIG move. So the auditor recommended that the clinic refund the $369,000 in the overpayment. They recommended that they come up with some type of payment plan in the required 60 day repaying it all. They’re required to return the money in 60 days and to establish adequate policies and procedures which the defense council agreed to in that case. So right now that case is on appeal and but there are five levels of appeal so OIG issues a recommendation or a report, it goes to their Medicare management company, and then they send a demand letter to the clinic and then they have the ability to appeal but there are five levels of appeal and they have to go through all of them. So as you can imagine there’s quite an expense with this. What many chiropractors don’t know is that often their malpractice insurance will cover the cost of an audit so that’s something really important for you to look at if you ever get a request and need to hire a lawyer.
Brad, you can go to the next slide. All right. So importantly in this, why did they get flagged? One, the documentation was, they said OIG not in auditors then was not sufficient. Another reason the 98942 used 98% of the time, that’s the problem. Because you get red flagged with that, are all your patients at the 98942 level? Next one Brad, if you don’t know how to code, you need to ask somebody like Bharon and there are coders out there that specialize in and have their certification for it. So if you don’t know how to properly code and that was one of the defenses in that case is that the doctor in the office manager said, “We didn’t know the five levels, meant five different levels.” I thought it was just where you were complaining and then if you had those different complaints, they just didn’t know.
And as Bharon said a lot of times it’s just because the doctor doesn’t know, it’s not an intentional thing, next one Brad. Accurate medical records. Obviously, in this particular case, how did OIG find or the auditor find 100% of the records were not appropriate, they didn’t document the proper medical necessity? Before you turn, when that requests was made for the 105 case examples, no, you can’t change your records, but don’t you look through the samples that you’re giving them and hope and look to make sure those medical records are accurate. Next one, good documentation not only help the patient care, but it will give you peace of mind so if an audit is requested you have some peace of mind to know that your records are proper. And in the last little bit of time I have penalties, the penalties are significant for the fraud billing, for services not rendered there is prison time for it if you’re making false claims. Five years, can result in a 10 year sentence for each offense. Fines in this particular one, obviously, they want all their money back, but if there is a false statement you can have fines for up to $250,000 for offense. Organization, sometimes you have the multi-disciplinary practices and you’ll have more than one specialty alleged to have been making false claims. So you’ll have multiple counts of healthcare fraud not just one but you’ll have multiple for the different positions involved.
Restitution as in this particular case they asked for their money back, and probation to make sure you’re continuing to do things properly. There’s always something that they’re usually going to request. So the next slide, if you think that you have a problem, next slide Brad, then what are you supposed to do? Well, then you can go to the last slide Brad. If you think you have a problem, you’re gonna wanna do and maintain your lead that have across for another on particular issue, if they sent to the issue, immediately stop filing problematic bills. If you can sense that what the problem is, stop filing those bills, seek legal counsel. Now some of them you’re gonna have to pay you’re audit a single major medical company in that will be a request. If they’re looking for a couple $100, $300, you don’t always need legal counsel but if it’s in a question the OIG which is the big deal, you’re gonna wanna seek legal counsel when that requests for the audit has taken place. There is a program through that you can return the overpayment to determine what you collected in there and run those numbers from patients and then you can report overpayment if you think you did it improperly.
And just untangle yourself from suspicious relationships. If there’s somebody else in the practice that has caused… remove that person from your practice earlier. OIG’s website has a lot of very, very helpful information on Medicare audit, which you can consider as well. So those are primarily in this short amount of time I wanted to give you a case example to show you it’s nothing to take lightly but as Bharon said, we don’t want you to be scared, we just want you to be able to document properly, code properly. So you are telling your story, you’re doing things the right way. So if and when you get a request for an audit, you don’t have a heart attack, feel like your whole practice, everything you’ve been practicing for is going to go down the tubes. So thank you for listening. I’ll turn it over.
Daniel: OK, very good. Well thank you Kim. That was a [inaudible 00:23:50] and now moving on to Brad Cost. Brad, would you like to briefly introduce yourself?
Brad: Absolutely, thank you Daniel. I want to first start by thanking Kim Driggers and Bharon Hoag for co-presenting with me on today’s topic. It’s a very important part, I sort of consider the entire process a three legged stool, three legged kind of system and as Bharon pointed out in the beginning the business process is definitely the documentation is a very important part of the process in it. The support system that falls onto that is where I sort of consider that the data falls into its place. I’ve spent the last several years of my life traveling around the United States holding classes trying to get doctors to become more aware. And one of the processes that I find interesting is how doctors somewhat remove themselves from the business process. I’m asking doctors and encouraging doctors and showing them why they need to reengage into that business process today. As we move forward with the future of health care, how the profits will involve much more data, how the process will involve performance based metrics I think it’s very, very important that the provider is involved in those scenarios. And also the team members that he has in place with the office managers and the rest of the staff there filling claims and providing follow up documentation. I think it’s very important that they’re all involved, the whole state involved in continuing education and realize that there is an entire support system out there to help them whenever something doesn’t seem quite right, and the key is finding a way in the beginning to determine whether something is going off the track.
And that’s where I found that data is a very important, can be a very important part of that process. And first in understanding who is it that is looking at my data, and what does data have to do with triggering an audit whether it be a payer audit or an OIG audit. Really, it’s important to understand that user provider is being profiled about who you are, what kind of services that you provide, what kind of patients that you see, and how many visits, and what you’re doing within those visits exist on each and every one of you out there in the world. And it is better to understand that profile than following away from that profile and not understanding it. It’s probably the reason the 98942 has used 98% of the time. Doctors don’t really realize that that is happening to them, that that is what’s triggering an audit in many, many cases. So let’s understand that there are the government is looking at you profiling you through your Medicare claim processing, insurance payers all the commercial private insurance companies have built profiles on you and the population around you in your State, in your region to understand how the population is performing.
And then there are provider networks, we get involved in networks and we have intermediaries that perform profiling on us each and every day. There are several around there that do that in a very detrimental way to us and it’s very important that we understand that they’re trying, which one of those there are and which ones are doing in at a detrimental way and which networks are out there to truly support us in a way. So paying attention to your data and understanding that is really the first step in understanding the entire process and what triggers those audits. Really and truly in those audits they’re looking for these patterns, these working patterns. What are the charges and services billed per month and that’s one of the things that we’re doing as a pro-advocacy company for you in the profession. One of the reasons we’ve been trying to drive home to be part of our clearinghouse to be part of our national network that we’re building, we currently have 28 state associations that have joined into that, but we have to get you as the doctors involved in joining that network so we can help you understand your data, help you understand your patterns and some of the things that we do and some of the analytics Infinedi tries processing out, looking for those patterns and developing those profiles ahead of time so that you can truly understand what’s going along, what’s happening within your practices. And by simply using us as a claim to clear your house in a pro-advocacy way, we’re able to pull that information out and help you understand that. Looking at what CPT codes, what diagnoses is already you driving to the pair that you’re showing.
We have a great level of analytics currently but we’re moving to the future trying to provide warning tools that’s gonna prepare you on a day to day basis and let you know are you in a normal level, are you exceeding that normal level, are you in a danger zone when you’re letting out some of these audits are over utilizing some of these audits. One of the other things that they look for is how big of a problem is fraud and abuse? It’s probably been number one driver in the health care profiling in analytics just trying to fraud, that fraudulent use. These are some of the simple graphs that we use called Scatter graphs to look at the population which each one in this case, each one of the blue dots represents a provider.
The bottom line or where those dots begin is what we call the statistical means. We’re looking at what is the mean of the population, what is the average population doing as far as performance, as far as charging this, as far as services especially looking at the dollar amount. And as you can see there’s dots what seems like are all over the chart, but if you go up two lines from the bottom line we call that, each one of those lines of deviation. It’s really what we’re trying to do is look at two deviations off of the standard means. We were saying that everybody that falls on those two deviations are part of the normal population. It’s those dots that are above those lines that fall out and are above and beyond normal and are in abusive level or actually possibly a fraud level. So it’s trying to let doctors understand when you get to that level, are you falling into that profile where you’re above and beyond and you’re at the risk of being triggered for an audit.
So it’s helpful to understand where you are, and at Infinedi clearinghouse and Infinedi analytics, we have the tools and the technology to do that on a day to day basis, a monthly basis, a quarterly basis and an annual basis, so you yourself understand it. How big of a problem is fraud abuse and why do we actually need to reduce fraud and abuse? You know the Pareto principle is a principle that’s named after the economist Vilfredo Pareto that specifies that an unequal relationship between input and output. The principle states that 20% of the invested input is responsible for 80% of the resulted outcome. So really what it’s trying to say if you look at it is 20% of the problem causers cause an issue for the rest of the 80% of it. So if it’s very important that we help the payers understand that the vast majority of the providers are not in a fraud and abuse kind of way. That we can simply reduce that by eliminating those doctors or helping those doctors that are in a fraud and abuse profile to move out of that scenario. And as Bharon says being in the business process works. Then when they understand it all makes sense to the payer. So it’s actually trying to help the payer or the groups that are profiling this understand what happens in Chiropractic. And I know from personal experience just like Kim, and Bharon does that insurance payers do respond to that invested feedback. They wanna hear that today, they wanna understand because chiropractors are the most cost effective health care that’s out there.
They may not fully understand that and I think it’s our responsibility as an industry to help them understand why it’s most cost effective, how that we can help their overall dollars spend be a much better dollar spend. Again, to look at the radar kind of things that we’re looking at, things that you wanna watch for that we’re going to help you technology wise. What are the percentages of the 98940’s the 41’s the 42’s, what percentages of the practice so you out there utilizing, its does codes that are called from the issues that we find from previous audits. Don’t use the same diagnosis on every patient, don’t get into those patterns with the same things for every patient. We’ve got to find ways to help you understand when you’re doing that, when you’re practicing that way. Don’t have the same treatment protocol on every patient, vary the services, vary the visits. It doesn’t make sense that every patient that walks in the door gets the same treatment protocol. Make sure that the episode of care links is appropriate for each diagnosis. That the episode of care link is appropriate and that there are no advanced beneficiary notices that are going on. Those are key triggers into what’s happening. Today, the Infinedi analytics we’re developing the current cutting edge tools that are gonna allow you as a doctor. Over the last few years, I’ve heard a lot of frustrated doctors tell me, “Brad, I just don’t have time to look at anything new. I don’t have time to be involved in the business aspects of my business. It is just too time consuming. I as Bharon said I just wanna be a health care provider.” They just want to raise their hand and snap that finger and not be involved into that.
At Infinedi analytics, Infinedi clearinghouse we’re developing the tools to help you do that. We just recently and uploaded to the iPhone and Android app store a new iPhone app so that if you’re our clients, your analytics will be at your fingertips every Monday morning. Thirty seconds with this app will tell you everything about the business profiling and process that went on the prior week to you. So in 30 seconds, one time a week, you at that snap of your finger will have a lot of analytical information. A lot of prospects about what kind of claim errors went all, what were charges by pair, what kind of charges and services did happen so that you’ll truly know in your outbound stream what occurred in the claim processing. Typically, we represent 95% to 98% of the income stream that you have outbound. This is a way that we can capture and help be your pro-advocacy. This business app we’re giving to our clients at no additional charge so that we can help them and they know that we’re here to help out and watch out for them. So with that, I want you to understand that final leg of the process, that final leg of the system is the support system that is technology. You can’t push it away even anymore, you’ve got to grab it and embrace it.
It’s part of today, It’s gonna be a bigger part of your future as we move to SCRs as we talk about MIPS, as we talk about navigating the APMs those alternative payment methodologies which we’re gonna be talking a whole lot about this next year. Becomes much more complicated, you have to embrace that data, you have to become part of that data. And with that I’m gonna say thank you. I hope that you understand we are all here for your edification to help you out when you have problems, when you have questions. If you’re in the Florida area, we’re gonna be teaching a much more extended version of auditing that you’ve heard today please join into that class. It is the CEU class that you can get credits if you’re part of the Florida Chiropractic Association and we even look forward to just your input in being part of that class. And with that I’m gonna turn that back to Daniel for questions, thank you again.
Daniel: Well, thank you Brad. This has been the variant of informative talk and along the way we’ve been collecting some questions from the audience, I’ve got a couple for each of our speakers. For Bharon, a doctor would like to know what is the single biggest coding mistake that seems to trigger an audit?
Bharon: I don’t know if there’s a single thing, it’s really the whole story together, but I’m a firm believer that you can’t build a house without being on a solid foundation. And most of the foundation for a chiropractor is your evaluation and management code, your ENM code. A lot of Chiros call them an exam code, it could be like your 9920 codes, or your 9921 codes depending on the type of patient you’re dealing with. And most people choose to lower the level of the ENM so you’ll do like a 99202 or a 99212 because you wanna fly under the radar. You think if I do a low level ENM that I won’t be triggered or at least sought out for an audit and it’s actually kind of the exact opposite. This is why I’m so adamant when I teach coding that you have to tell the story. If you did the work to qualify for the code, bill the appropriate level. Don’t be afraid that you’re going to get singled out because you’re billing a level three or a level four if it’s appropriate for that particular patient.
The other issue that I have with ENMs is a lot of the consulting companies are teaching in order to attract new patients to give away your first visit. Well, look at this from a claims perspective standpoint, if I’ve never seen a claim come to my payer from you and the first one I get are loaded with diagnoses and just a bunch of treatment that you never communicated to me that there was an exam, I’m wondering where these diagnoses came from. How can you tell me that there’s a subluxation or a disk issue or any of these other things when you never communicated to me that you did a history exam, medical decision making counseling coordination of care. You looked at the nature of the presenting problem and spent a certain amount of time with them, which those are the certain factors in an ENM. So we’ve got to stop doing things because we’re afraid, we’ve got to start doing things because we wanna communicate the message and tell the appropriate story. So although there’s a lot of potential issues, I would say my biggest concern is ENM codes for providers.
Daniel: Right. And in pursuant to another question here then so basically it’s up-coding and down-coding tend to be red flags that trigger audits?
Bharon: Sure. Yeah, it’s just don’t code because you think this is what they want, code because it’s what supported by your documentation and that’s the work that you did. Because at the end of the day should you ever make it which I understand maybe less than 1% of a chiropractor will ever be on the stand having to question their documentation. But in the event that you ever get there, you wanna be able to talk directly from your heart that I know what I did, this is what I did, this is why I coded it. If you’re playing games and you’re diagnosing things because someone said, “Hey, bill that diagnosis or bill that particular code”, because they get you paid, you’re gonna have a hard time when you’re on the stand defending yourself, because you don’t even know why you did it. You did it, because someone told you to. So it’s not, I don’t believe that chiropractors get in trouble because they’re literally trying to milk the system, I think you get into trouble because you’re trying to not be noticed and therefore you’re still not telling the accurate story which makes you more visible.
Daniel: Very good. Well, I think that’s very consistent with everything that you were presenting today. For Kim, I got a question for you. There are a number of negative aspects of audits, do you think that chiropractors fully understand the nature of how dangerous audits can be for them?
Kim: No, I definitely do not, however, we think that pendulum is changing. There are several that speak on Medicare audits. Now, one of the experts in the country, Steve Conway out of Wisconsin, he is actually and I think as Bharon indicated he has in the past met with those adjusters those reviewing the claims for determining audits and he told me yesterday where the requests for audits was at 80%, that pendulum has swung down to 30%, and they couldn’t believe, or I’m sorry 80% error rate down to 30% error rate. And the adjusters even notice the claims people could not believe that that pendulum swung that much, and why is that happening? It’s happening because there is more education to doctors out there as in this webinar today. As in, the Florida Chiropractic Association having an hour, almost a two hour long of which had course on it. But also them speaking with those who are doing the audit informing them, educating them because they’re making mistakes as well. So I don’t think the doctors know quite the severity or the punishment or the fines that are occurring out there but we’re focusing on our job which is to educate more and to hopefully make that error rate even lower than it is.
Daniel: You know you mentioned fines and recruitments during your talk, a doctor would like to know can a chiropractor go to jail.
Kim: Yes, they’re. Certainly, yeah, you can go to prison if there’s a criminal penalty so for violating, billing, unlawfully billing, billing for services that aren’t rendered. If it’s through fraud yes, certainly you can go to prison for it.
Daniel: Very good. Well, thank you. And for Brad, I’ve got a question for you. What do you see as the future of technology involving audits?
Brad: Well, Daniel you know health care is gonna change drastically as I mentioned in the future, and technology is just a piece of it. How the data systems are being utilized in the performance space metrics are gonna have to be a part of everyday life, because the payer is looking on Centrino and the providers becoming a part of the cost savings. And so technology has to be there to help the provider understand that performance level, how they can be better informed and about the cost savings, how they can use technology to keep the patients better informed about the services. We’re seeing that today with Medicare on MIPS We’re developing tools in that area as we speak that we’ll be bringing to the chiropractic world next year. It’s really just another support system to help characters and that’s the message is Bharon said it might be getting tougher but the support system is growing better. It’s out there, we just have to get the doctors to engage and utilize that as a support system. We’re throwing life lines to you, don’t push them away, become a part of them, embrace them.
Daniel: You mentioned IPAs as a prevention solution. Could you explain that in just a bit more detail for us?
Brad: Sure, I started talking about IPAs but Independent Position Associations, we’re involved with those all across the United States. Kim’s, part of Kim’s company SecureCare has set up networks to be networks that are owned by the state associations, so state chiropractic associations and with that comes an amazing level of utilization management. We’ve built those systems from Infenedi analytics to help doctors stay in utilization management guidelines. So being part of a state association, belonging to an IPA automatically throws you into that supports system that keeps you out of trouble because they’re looking also at your profiling, and they’re looking at your claim strength that they’re gonna get all of you, they’re gonna hold your hand walk you through when there is a problem, and be there to stand by you if you do get then into trouble. So for me it’s just that third leg of the stool is belonging to your State Associations, belonging to the IPAs, belonging to the National Associations. It’s all part of a group of people that are just trying to help with that.
Daniel: Well, very good. And thank you very much Brad, Kim and Bharon for today’s talk and at this time we would like to thank our sponsor Infinedi and Brad Cost for today’s webinar. Thank you all for attending. Remember this webinar, including our speakers’ PowerPoint presentation has been recorded. If we didn’t get to your questions during the webinar, they’ll be posted to our experts and the answers posted online at chiroeco.com/webinar. Thank you again everyone for attending, and we look forward to seeing you next time. Have a wonderful day.
About the speaker
Brad Cost became the chief executive officer, president and owner of Infinedi, LLC in 1999. He is a highly knowledgeable and credible source within the healthcare and data analytics industry. Cost has an impressive work history proving his success and owns various companies including: an electronic data interchange consultant firm, an interactive software development firm, an innovative software system and many more. His primary focus is in the development of cutting edge electronic data technology as it relates to the big data analysis of medical and health data.