Here’s the bad news you already know: an increasing amount of good chiropractors are being audited by insurance companies and asked to repay hefty sums due to “insufficient documentation” or “improper coding” or other practices that somehow get viewed as substandard.  And the ensuing mayhem that this creates is destroying many practices and robbing more of profits.

Here’s the good news: for those of you who haven’t yet experienced this first-hand and who would like to learn an “insider’s perspective” on how to protect yourself, read on.

As a matter of disclosure, I used to work for “the other side” as an Insurance Claims Analyst prior to becoming a chiropractor.  I am also Certified Professional Auditor and Certified Professional Coder which only means I received the same training as those who are trying to take your hard earned money.

Just for the record, I have never performed an Independent Medical Exam, Audit, nor any other such work for an insurance company while a chiropractor (nor do I intend to!).  On the contrary, this article is focused on how to help you avoid this monster and how to protect yourself when he strikes.

While audits are too commonplace to be considered earth-shattering news (by now, most of us either know a DC who has been audited or have personally been through an audit), it is surprising – even appalling – how little knowledge of chiropractic, correct coding initiatives or even documentation standards are possessed by the auditors themselves! Even if you have not been audited in an “official” manner by Medicare or some third party insurance payer, the next time one of your claims is reviewed by an “Independent” Medical Examiner, this message may prove useful to you as well.

How to Fight Back And Hit ‘Em Where It Hurts

When you are audited or have your claims reviewed by some IME (sorry, but the reality for most DC’s today is WHEN not IF), here are some fighting tactics that are effective and easy to use:

  • Check out their credentials. You may be shocked to find out that your auditor or IME have absolutely no qualifications to review your claims, other than the need or willingness to take a check from the Insurance Company (or Third Party Administrator).  Insurance companies routinely deny or demand repayment based on codes that contain high error rates (For example, 97140 or 97112). However, just because an auditor says you used them incorrectly doesn’t mean it is necessarily the case.  After all, does he have enough experience with chiropractic to know how you are performing the procedure, is he a certified coder who can adequately judge the usage, or is he simply acting on statistical norms and assuming you are wrong?
  • Don’t write a letter asking for your research to be considered, demand that the reviewer/auditor be a licensed chiropractor in your state.  This will automatically kick aside the DC who sits in his comfy chair across the country performing paper reviews on his unsuspecting colleagues.  This also gives the boot to the nurse who is making a nice income auditing chiropractic claims despite the fact that she has no technical knowledge of chiropractic.
  • Demand that the reviewer be in active practice AND that they do not derive the majority of their income from performing reviews or audits. I like this step because it really levels the playing field. After all, not many reviewers are going to bite the hand that feeds them – especially if that hand gives them most of their food!  You are much better off being judged by some chiropractor who is trying to make an extra buck or feels some sort of moral obligation to cleanse the profession of the crooks and therefore performs audits on the side, but still gets most of his money from practice.
  • Demand to See the Actual Notes of the Reviewer/Auditor – Not Just the Final Summary.  I have seen too many clients get out their checkbooks to write the insurance company a check for a failed audit when they have not examined the details of what made them fail.  The average audit tool contains 18 items — wouldn’t it be nice to know which ones were at fault so you could correct them or (even better) dispute them?!  Get the specific records reviewed, treatment dates, and what specific items were at fault or substandard.

Obviously, there are more tricks to use and traps to avoid. If you don’t know where you stand, consider taking my Billing Quiz to give yourself an overall status report on common mistakes that are either costing you money or exposing you to trouble.

If you’re in the Northwest (or would like to be) in October and November, you may also want to consider attending one of my Seminars where you will be treated to live demonstrations of the split-second type of destruction a cranky auditor can inflict on your practice. And, of course, what to do to prevent this mayhem.  Oh, and how to increase profits while decreasing your audit risk.  In other words, necessary tidbits that will save your tail and bolster your bank account in the process.  Hope to see you at a seminar soon!