In Part One of this article “How to Survive a Chiropractic Audit” we focused on what to do if and when you get notification that your chiropractic practice is being audited.  My primary focus in that article was to prevent you from having a heart attack, from fleeing to a fortress in Slovenia, from unnecessarily declaring bankruptcy or from throwing in the towel and ending it all.  Unfortunately, in my work helping chiropractors with their audits, I’ve seen all of the above

(Ok, maybe not fleeing to Slovenia, but if you’ve got to leave the country, it’s a nice place to be, especially around Lake Bled in the summertime…But I digress.)

In Part Two, we are going to focus on being a little more proactive than having your passport ready or your fingers crossed.  Let’s focus on preventing the audit.

Why Audits Happen

While audits may sound mysterious to you, it’s only because you are hopefully unfamiliar with them.  However, audits are no mystery.  Sure there is the “random” audit that is essentially a payers way of attempting to put fear equally into everyone with equal odds.

Primarily, though, most audits happen for a few reasons, all of which are generally related to your status as an “outlier.”  If you are unfamiliar with that term, it’s a fancy way of saying you don’t look like everyone else.  Except we are not really talking looks as in your hair is brown vs you don’t have any hair or your practice is in the city vs yours is in the back of a barn, next to the manure pile.

Outlier status is generally focused on your billing and coding patterns.  Here are a few examples of things that will typically get you labeled as an “outlier” and a prime candidate for an audit.

How to Beg for An Audit

If you don’t like the above heading, you’ll see why in a second.  Most of the ways chiropractors get labeled “outliers” are largely preventable.  Here are 5 troublemakers that can lead to big problemos but could also definitely be avoided:

1. Excessive Billing:  Truth be told, no one believes that there billing is “excessive” save the nefarious few true blue fraudsters who know exactly what they are doing.  I don’t aim to help them and generally these idiots are all caught and sent to prison where I hope they meet up with the son of the momma whom they defrauded of her Medicare benefits.

But the “ignorant” (in the nicest sense of the word) culprits of excessive billing are typically chiropractors who have been taught some brilliant strategy by their practice management guru or from their best buddy who bought himself a new set of gold necklaces and his wife a new set of everything that God gave her with the profits from their little “billing experiment.”  Then, they repeat it ad nauseaum.

2.  Static Patterns.  This may be either the DC who is stuck in a rut or who oversimplifies everything or who deviously figure out that this is a profitable “pattern” for his Dx coding.

For example, I’ve seen chiropractors who have used the same set of diagnosis codes on every patient, time and time again.  One push of a button can reveal that your pattern is a little stagnant and worthy of some investigation.

3. Technology Traps:  Don’t get me wrong, I love EMR.  It massively simplifies most things in the chiropractic office. It can generally increase your efficiency and the quality of your documentation.  But it can also raise major red flags when your notes all look the same.  Beware of cloning, cut and paste, SALT (same as last treatment) – whatever you call it.  Regardless of the name, auditors hate it and will demand money back if they even sniff the possibility of cloned notes.

4. Dubious DME:  If every one of your patients needs a $1500 back brace or a $425 traction device, that’s going to draw some attention.  Sure, the insurance will pay if you use the correct code and you have a letter of medical necessity.  But they may begin to get suspicious when your DME numbers are 25x higher than other chiropractors in your area (or in the nation).  Certainly, you could just have a busy practice.  Or you could be working with a DME company that is “coaching” you into which products to bill for the highest revenues.  Bad news is the DME company gets their dough when you get paid.  But when it’s time to pay the insurance back, it’s you that get to foot the bill.

5. Super-Chiro Excess: AKA an excessive number of procedures either per day or per place of service. There are cases where, in order for this to look legitimate, the chiropractor would have to have traveled at the speed of light to see all those patients. Wow, Super-chiro, you were able to adjust 12 patients, do manual therapy on 4, give three massages and go over exercises with 2 more patients — all in a single hour?  Surely, Super-Chiro you are not so… when the auditor looks into things, he finds a rather ordinary chiropractor who has a rather extraordinary lack of understanding on how to properly bill, code and document timed services.

6. Delegation Disasters.  This one is usually coupled or compounded by number 4. Chiropractors who lack of a critical understanding of how to properly delegate services to meet the payer or state’s definition of supervision are flirting with danger.  Honestly, most DC’s believe they understand this rule.  But over the last several years, I have observed hundreds of practices that clearly demonstrate that they don’t have a clue.  Worse, they don’t know the danger that they are in if they screw this up.  Penalties range from repayment to being kicked off the insurance panel to being disciplined before the state board — none of them good.

7. Upcoding of Procedures:  There are also plenty of chiropractors who are guilty of upcoding. Whether they do this intentionally or not, the fact remains that these DC’s consistently submit codes for services that are more complex than was rendered or documented. If you compare the statistics, this anomaly becomes obvious. There are chiropractors who will a 98941 (3-4 region adjustment) for every single date of service for every patient they have.  Upcoding can also take place with E/M codes whereby the chiropractor bills a higher level new or established patient exam than they really deserve.  Fraud?  Not usually.  Again, most of this is pure, honest, unadulterated ignorance.  We just don’t know or understand chiropractic coding.  Our billing reflects it. And our documentation won’t save us.

What will save you?  Oh, haven’t you had enough for today?  I’m pooped and headed to my castle in Slovenia.  You’ll just have to wait and look for How to Survive a Chiropractic Audit PART 3 for what to do next…