A quick glance at healthcare news will reveal that chiropractic audits in 2020 will see an increase again thanks to the fact that they are perhaps the best return on investment the federal government sees with the Office of Inspector General’s program (or perhaps any program). While this may be good news for the OIG’s coffers, it’s definitely bad news for you as chiropractors. Here’s why and how they plan to step up audits against chiropractors (again).
Follow the More Money Trail
It’s no secret that auditing is big business — and chiropractic audits in 2020 will be one spoke in the wheel of that big machine. In fact, it’s boldly proclaimed by the Inspector General Daniel Levinson himself within the first several pages of the OIG’s 2019 fiscal year budget report requesting more funds to do their work. The statement is plain and simple:
“…the OIG returned $5 to the Federal Government for every $1 invested.”
Certainly, there are fraudsters out there who need to be caught and stopped. But before you believe this is a noble fight of good vs evil, consider the players at hand. The auditing is not done by impartial employees with a specialization that matches your professional credentials or healthcare specialty (DC, MD, DO, etc) so that they have an understanding of the services you render. Instead, the bulk of auditing is done computer algorithms designed to find “outliers” and identify suspicious patterns. Some audit and post-payment demand letters go out without a human ever setting an eyeball on them (as evidenced by the “form letter” nature and similar appearance of thousands of letters). Others are scrutinized by hired contractors who are skilled and credentialed (hopefully) in the process of nitpicking your notes or questioning your coding. But they are also financially incentivized by the amount of money they recover. In short, they are paid when they take your money back, not when they say your services and documentation are acceptable.
Obviously, there’s a big conflict of interest in the hands of those who do the auditing. But the financial conflict starts from the top down. Naturally, if the government can give $1 to the auditing arm of Medicare (the OIG and their hired henchman) and get $5 back, they are going to think highly of the program. Thus, the OIG’s request for $20 Million more to fight fraud, waste and abuse will likely be approved.
New Tactics For Chiropractic Audits in 2020 and Beyond
To recover these funds, the OIG has recently stepped up its game in the hunt for fraud and will continue to do so in 2020.
In December 2019, the OIG began launching Facebook Live campaign designed to educate consumers about what healthcare fraud looks like. The video was viewed over 1200 times in the first 24 hours, which I’m sure attracted was a smashing success for what is not normally a topic that one would expect to see a viral video.
On the video, consumers asked questions and the investigators responded time and again with the same basic response: call the Medicare fraud hotline. But even if you don’t want to wait on hold via the telephone, the OIG also has an option to report healthcare fraud online – including potential Medicare problems, HIPAA privacy violations, discrimination and more.
And to top it all off, the OIG has even introduced a new way for concerned consumers to leave anonymous fraud reports which will be investigated as well.
Not Necessarily an Audit Target But An Easy Audit Trigger?
Chiropractic audits in 2020 may also see a sharp increase thanks to the forthcoming modification or update of the Advanced Beneficiary Notice (ABN). Although the new version has not been issued at the time of this writing, one thing is clear: the current ABN that chiropractors are to use is expiring in March 31, 2020.
While the ABN is not an audit target in and of itself, improper billed services that were deemed maintenance care is a perennial problem for chiropractors.
So, it’s not hard to picture a “double-whammy” scenario where chiropractors not only provided “non-medically necessary” and non-covered services to patients (maintenance), but they also do so without a proper ABN. Worse yet, it’s possible that chiropractic audits in 2020 could nail a chiropractor for using an outdated version of the ABN – in other words, they took the right action, with the wrong form!
May Be ARE a Target
Unless you’ve been hiding under a rock, have attended zero CE seminars, refused to read any chiropractic publications, withheld the urge to join webinars or consume any outside information regarding our profession for more than a decade now, you undoubtedly have heard that chiropractors are and have been historically having a bit of trouble with Medicare audits (and other payers as well).
Chiropractic audits in 2020 will continue and likely increase because of the simple fact that chiropractors have been targeted by almost every OIG audit agenda since 2005, including the most recent work plan in 2018. The headlines are a bit scary but easily point the crosshairs at chiropractors.
The recent examples range from a chiropractic office that was audited and fined $169,737 for what stemmed from $1,042 in disallowed services that were billed. Similarly, a DC in Florida was found to have billed $1,680 in error and had to pay a whopping $317,038 back.
While those examples showed how large a Medicare post-payment demand can be with a relatively small error rate and the huge mathematical process of extrapolation is applied, others were big numbers and big math. A chiropractor in New York, for example, was found to be billing 95% of all claims in error and a post-payment demand of over $500,000 was issued.
Long story short, the OIG summed up why chiropractic audits in 2020 will continue to be a focus of their audit work:
“Chiropractic fraud, waste and abuse is a concern. Medicare continued to make hundreds of millions in improper payments for chiropractic services.”
WHAT TO DO NEXT
Sadly, many chiropractors are still confused with Medicare billing, coding and documentation requirements and will likely be the recipients of chiropractic audits in 2020. Others don’t really understand the rules of Medicare compliance, what can and cannot be done in the name of discounts, free services or with respect to non-covered services. Here are a few simple suggestions of what to do next to prepare:
- Watch out for the new ABN to be issued soon – the current version can be found here but expires 3/31/20.
- Protect your practice with audit insurance. The fortunate few who have seen zero audits, zero claims denied and have zero potential compliance violations within their practice are getting smaller in number each day. For everyone else, a good defense plan is needed for WHEN the audit happens. In 49 states, a great option is ChiroHealthUSA’s Defense Plan which combines their compliant discount procedures with audit insurance protection through NCMIC.
- Offense AND Defense Wins the Game. I know there a lot of trite sayings that talk about the best offense is defense. But the fact of the matter is that if your team scores 0 and the other team scores 0, you don’t win, you tie. Sadly, in audits, there are no ties. Even if you come away clean and don’t have to pay back a single dime, you lose. The money you will spend, the time it will take, the anxiety an audit causes all equal one clear result = you lose. The reality is you do need defense. But, on the offense, you need to take concrete steps to PREVENT an audit from happening, to reduce your chances, to strategically participate only with payers that are worth the risk. Most chiropractors blindly jump and join every plan they can – with no regard to what they can and cannot bill or get paid for, what the audit risk of participation is and with no forethought on whether it is a good business decision to do so. We must learn to bill, code and protect our practices. But we also need to strategically play the game with only the best players and payers! To do this, you must attend webinars and seminars to help you stay on the top of your game. Chiropractic Events like these are the only way to keep current and stay updated on changes that affect you and your practice.
If you’d like to avoid chiropractic audits in 2020 AND to improve your practice, consider attending our upcoming Chiropractic 4.0 Seminar in Seattle. Yes, the game has changed and this event is designed to help keep you up to date on the latest insurance changes and how to navigate into better waters for your practice survive and thrive in 2020 and beyond. Click the link above for more info and to register.