To fly under the government’s radar, pay close attention to your documentation.
The Office of Inspector General (OIG) and bandwagon-hopping private insurers are going after fraudulent practitioners because the government, unsurprisingly, prosecutes criminal behavior. But equally significant is that hunting for fraud is highly profitable: Fines and recoveries from major offenders can earn the Feds and other third-party payers up to a cool million per audit.
Most DCs aren’t deliberately and knowingly breaking the law. They make documentation errors not with the cold intent to defraud, but from sheer ignorance or information overload. But even if you’re not one of the big offenders—the droids, if you will—that the auditors are looking for, that doesn’t mean you can breathe a sigh of relief and ignore your documentation. The OIG has estimated over the years that anywhere from 80 to 95 percent of chiropractic documentation is incomplete, incorrect, or both, and you can get caught in the same net they’re using to scoop up the big fish.
They won’t throw you in prison if your documentation is simply sloppy and spotty as opposed to criminally misleading, but they can still make your life extremely difficult and demand enough in recoupments to put you out of business.
No room for error
So, job one is to get your documentation in impeccable shape. It takes time to put procedures in place, but it’s far easier to do things right the first time than deal with time-sucking records requests or, worse, the extensive time and stress spent preparing for and recovering from an audit. Here are some ideas to get you started:
Make sure you’re using the most current codes. This includes Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and ICD codes. For now, that would be ICD-9 but, before you know it, October 1 will arrive and you’ll need to be using ICD-10. Now is the time to prepare. If you haven’t already learned which ICD-10 codes you’re most likely to be using and put together a reference sheet, you’ve already fallen behind.
Learn to speak fluent modifier. If you’re not using the correct modifier, you’re not going to get reimbursed. It’s as simple as that.
Familiarize yourself with your carriers’ medical review policies. Most of these can be found online. If the insurers you participate with have specific rules and you’re not following them, you’re in violation of the agreements you’ve signed.
Submit complete documentation. That would be documentation that has the correct dates, codes, modifiers, treatment plans, notes, progress reports, duration for timed codes, and the practitioner’s signature. Across the board, an unbelievable amount of chiropractic documentation is missing some or all of these details.
Get clear on medically necessary versus clinically appropriate care. Everyone with a spine deserves ongoing wellness care, but that doesn’t mean third parties will pay for it. Medically necessary care is episodic, with a clear beginning, middle, and end of treatment. It’s also care undertaken with the reasonable expectation of progressive functional improvement.
Weekly adjustments may well make a senior’s arthritic hip feel better, but they won’t be considered medically necessary without documented functional improvement, and Medicare isn’t going to pay for them.
Beware of documentation red flags. Auditors look for under- and over-coding because billing too much or too little puts your practice outside the norms. They also watch for what appear to be cloned records, i.e., when all your documentation looks the same. Make sure each visit and its documentation is encounter-specific. Overuse of a code, or too many notes that say something like “same as last visit” make your documentation stand out. You don’t want that.
Feeling confident about your records but still getting rejected claims? Time for your next step: Appeal them— every last one.
Stand up for yourself
Here’s an insider secret that comes courtesy of a former insurance claims adjuster: Up to 30 percent of all claims submitted to insurance carriers are denied on the initial submission whether they are correct or not. Why? Because only about 25 percent of chiropractic practices spend the time and energy to appeal rejected claims. In other words, it’s profitable for insurers to randomly reject claims because they know most DCs won’t push back.
Just as it’s beneficial for third-party payers to randomly reject claims because statistics tell them you won’t put up a fight, it’s worth your time to write standard operating procedures for appealing rejections and follow them faithfully. Some DCs worry that appealing claims will result in more rejections, but this isn’t true. You won’t be punished for submitting appeals. And you stand to win with increased reimbursements and a far more robust bottom line.
So you are likely not one of the droids they are looking for. But that doesn’t mean you will be overlooked. A small fish may make for a puny meal, but a net full of many small fish can feed a village—or the coffers of a third-party payer—quite nicely.
The OIG estimates its 2014 recoveries from audit recoupments at nearly $5 billion. Even if you’re not a droid, take steps to make sure you aren’t somebody’s dinner.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. She leads a team of 14 at KMC University and is known as one of the profession’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562 or firstname.lastname@example.org.