Admittedly, there are some things we cannot do in regards to how the whole health care reform mess plays out.  One thing you can probably anticipate is that if the government gets involved, your level of paperwork, red tape and scrutiny will likely increase. Certainly, this is not good news to any health care provider – regardless of specialty – as most of us feel overburdened by documentation, billing or coding rules and regulations as it is.

In reality, many chiropractors are already getting a taste of what it will be like to be under the microscope.  By now, most states have Recovery Audit Contractors (RACs) – the hired guns employed by Medicare to audit your claims and demand their money back – in full force; the remaining states will begin to get audit requests from the RACs starting August 1.  Yes, that is August 1, 2009, just a few days from now.

As many of you know, I recently became the first and only chiropractor to achieve the designation of Certified Professional Medical Auditor.  In other words, I went through the same training that many of these RACs and most insurance auditors went through to learn how to quickly assess whether or not your billing, coding and documentation met appropriate guidelines and standards and/or was billed and coded correctly.

It was an eye-opening experience for sure and somewhat humbling, as chiropractors are generally regarded as pretty low on the health care food chain.  Anyway, I thought I would share a few “tricks and traps” I learned on my summer vacation with the auditors.

Audit Practicalities and Audit Economy

Most audit tools used by commercial third party payers such as Blue Cross, Aetna, Cigna, etc have a fairly small number of items that are analyzed from a records and/or claim.   The most common number I have seen is around 20 items, meaning that each item is roughly worth 5 points with a couple bigger items worth 10.

The reason for this is both practical and economical.  Practically speaking, if an auditor looks at your records and determines that you have missed 14 or 15 out of 20 items, it is very likely you will miss the same percentage on a larger scale analysis as well.  This also makes good economic sense for the insurance company paying for the audit because this means the auditor can physically perform more audits per hour or per day as opposed to auditing fewer records in more detail.

What this means for you, the target chiropractor, is that you have fewer opportunities to redeem yourself and score points in other areas to achieve a passing grade.  What’s passing? For most Audit Tools that I have seen, a passing score is typically 80%.  So, in a 20 item scenario where a couple items are worth ten points each, you can probably only miss 5 items before failing.

Beware the Low Hanging Fruit

Here is some advice you have heard before:  the low hanging fruit is the easiest target.

You can take this in a couple ways.

First, make sure you never lose points on “silly” audit items – i.e. ones you would literally kick yourself for, if you were to miss.  In this category are things such as Patient Demographics (patient name, address, birth date and appropriate demographic info in all charts) or Confidentiality Measures (HIPAA agreements signed, records releases obtained, etc).  These are items all offices should have in place.

Second, the low hanging fruit is also the easiest target for the auditor.  In other words, if you have been “faithful” in the smallest details, then you are likely to be “faithful” to the more difficult items an auditor examines.  However, if the auditor detects that you have missed even the most basic elements, then you have inadvertently clued them in to the fact that you office is probably unprepared.  Consequently, they will look very carefully at your records hoping to take advantage of your lack of preparation.

Audit Tricks and Traps to Avoid

In offices that fall somewhere in the middle (not totally unprepared for an audit, but not bulletproof either), the auditor must then go to his trusty toolkit of “tricks and traps” to ensure that you do not get a passing score.

While sitting in my auditing certification class, I became a little queasy learning some of their “tried and true” methods for separating the pros from the amateurs. Here is one that has probably knocked more chiropractors down a peg than I care to count:

Documentation of Allergies.

Certainly, many of us have new patients fill out an intake form that asks many questions regarding their health history, one of which usually pertains to Allergies.

But how many DC’s actually spend the time to ask what specific allergies the patient may have?  In defense, most chiropractors would probably state that this is irrelevant to the care of their spine.  Here’s where things go awry.

While it may be true that the fact that a patient who has an allergy has little to do with the safe delivery of their adjustment, it may be extremely relevant to a chiropractor who recommends, prescribes or sells supplements as part of their care.

Take for example, a chiropractor who recommends Glucosamine Sulfate.  Many DC’s routinely do this. Most Glucosamine Sulfate supplements are derived from shellfish. If the DC fails to properly screen for allergies and the patient has a shellfish allergy, he may be found to have substandard documentation. Worse, he may be liable for any potential harmful effects brought on as a result of taking that supplement because he failed to adequately inform, screen or warn the patient of possible adverse affects of taking the supplement.

Remember Whose Game We Are Playing

While this may seem like a strange thing for an Auditor to look for, we need to remember that when we bill insurance, we are playing in the MEDICAL arena.  And for many chiropractors, screening for allergies may have little impact on our documentation or practices, it is not the case for MDs who routinely prescribe drugs that could have serious consequences if allergies were not properly taken into account.

Bottom line: It takes 30 seconds to ask a patient about any allergies.  If you recommend supplements, you should familiarize yourself with common potential allergens that are contained in those supplements and make sure that your recommendations won’t interfere with the patient’s allergies.

And finally, be sure to DOCUMENT that you did this!  In the end, you must always remember, if it is not documented, it was not done!

Stay tuned in the coming weeks for more “tricks and traps” from the Auditor’s playbook.

Until then, keep your spirits up and write it down!

Tom Necela, DC, CPC, CPMA

P.S.  Did you know this information?  From quizzing seminar attendees, I would estimate that 95% of the profession is clueless about most of the billing, coding, and documentation requirements that I teach – despite the fact that some of the info is readily available in coding books, insurance contracts or provider websites (not that anyone has time to slog through all that).  Anyway, this means I should have approximately 50,000 U.S. chiropractors reading my blog and on my mailing list.  As it stands, I am several thousand DC’s short of this several times over.  While you are obviously in the top 5% of chiro-geniuses around (after all, you are reading my blog!), it is probably high time you help a friend, help our profession and send them to my website or blog so we can all continue to help our patients with chiropractic care.  Most everyone loves to receive something for free, especially when it can save their livelihood.  Thanks in advance for helping spread the word and for all your words of encouragement!  It is truly an honor to serve so many devoted stewards of this great profession.