In Part 1 of this article series, I introduced the “triple threat” that is looming around your practice attempting to take your money, your license and your good reputation down with it.  We discussed the fact that the most likely attacker would be a “secret shopper” calling on behalf of an insurance payer to determine if your office has a time of service fee discrepancy.

Also mentioned in that jolly good read was the admission that, while it is certainly no fun to cough up $1800 over a payer’s “rate adjustment” thanks to this type of thing, that’s just the tip of the iceberg.  The real damage is awaiting beneath the surface if the payer decides to do a full scale audit on multiple patients.

Guilty Until Proven Innocent?

Certainly those numbers get your attention, but I know there are some of you who declare that you are innocent (and certainly you may be)!  You don’t feel that your TOS discount violates any rule.  Or you may argue that your discount is only available to patients paying at the time of service (duh).

While I certainly agree with your logic and the fact that you may be innocent, unfortunately, the payers have chosen to take a different stance.  They did their undercover work.  They think you are guilty.

As a result, they will demand immediate repayment or offset your future checks until you can prove yourself innocent.  Un-American?  Welcome to Payer Persecution 3.0.  Yes, you still have an appeal left and you may win. But, unfortunately, because these stakes are so high, an appeal is simply not enough.

In the past, chiropractors who have been on the foul side of these scenarios have typically resorted to one of a handful of strategies – if any.

What to Do Next — Why One “Best” Defense is Not Best

1. Appeal — Those familiar with this blog or attendees of my seminars will note that one of the first responses should not be to simply write the check to repay the insurance.  A well-crafted appeal letter is in order before you admit defeat. And statistically speaking, well over half of all appeals waged will help you to earn/keep your money.  Unfortunately, there are two challenges here:  all appeals do not succeed and the appeal in this case is a reactive strategy, but not a proactive solution that will help prevent future bombs from exploding.

2. Compliance Training – Understanding the rules goes a long way towards prevention and with proper training, it is certainly possible to keep time of service discounts and fee schedules as black and white and compliant as possible.  Unfortunately, this appears to be lacking somewhat in practice, as evidenced by the questions I get at my seminars when I teach this stuff and is amply demonstrated by the number of complaints your state board handles regarding fee issues (for which I am called to defend you by testifying as an “expert witness” far more often than I’d like).  Finally, I guess the real proof is in the pudding.  If most of us chiropractors thoroughly understood compliance, the rules and regulations surrounding proper billing practices, fee schedules and for that matter, coding and documentation, there wouldn’t be much for the insurance companies to chase down.  After all, logically speaking, our profession is too small for payers to care much about.  So why the onslaught of mystery shoppers, paper audits and fraud accusations?  Apparently, payers believe that “DC” must stand for “dumb chiropractor” and that it is easy for them to do a little digging and strike gold. Sure, they could get $150,000 back from a couple surgeons who didn’t cross their t’s and dot his i’s correctly – but $2000 from 100 chiropractors who barely put up a fight is obviously quicker and perhaps more effective in their eyes.

3. Phone Training – The phone appears to be your first line of defense and in some cases, it’s the chiropractor’s weakest link.  Far too many offices let just about anyone that can say “hello” answer the phone.  This is not only bad from a business perspective in that a poorly handled phone encounter can lose you a prospective new patient, it can get even more costly if your un-trained or poorly trained staff member gives bad answers to a payer.  In this respect, three simple strategies emerge as a must-do:

a) Do Not Let Untrained Employees answer the phone.  It’s simply too risky from any angle.

b) Teach your staff proper phone scripting and how to properly handle new patient scenarios from a new patient generation AND from a compliance                    perspective.  While some offices do the former and I know precious few who do the latter.

c)  Check Their Work!  Turn the tables and perform Mystery Shopper calls on your own staff to see if they are implementing your policies and procedures correctly!  (Or you can check out our Chiropractic Audit Armor service which does this – and more- for you!)

4. Billing/Coding/Documentation Training – whether you realize it or not, how you bill, code and document your services DOES matter and can help you minimize risk and get paid for what you do! Sadly, too many chiropractors face unnecessary battles (they won’t win) and expose themselves too much from a lack of knowledge in chiropractic billing, coding and documentation department.

5. Pay Attention – Another defense strategy is to not only be aware of your own self, but to pay attention to payer changes and audit trends. The hard part is that most chiropractors don’t have time to keep researching the latest tactics that the payers are using to cook your goose. (Obviously, this is why writing and speaking about payer changes is a major focus of this blog and my seminars and probably why we’ve had over 70,000 unique visitors to my blog, totaling nearly 500,000 page views and over 2.5 Million hits so far this year on the website. Considering that there are only approximately 60,000 DC’s in the world, these figures amount to the fact that a lot of chiropractors and their staff members are trying to keep up and pay attention.)

6. Ongoing Monitoring and More Training!  – Thanks to an ever-shifting array of rules, regulations and payer changes, one time training is rarely enough. New hires need to be taught the correct procedures, weak areas need to be improved and improper practices need to be eliminated.  And by the time you get the newbies ready, it’s about time to reinforce the knowledge base of your experienced employees. The only way you are going to ensure that is all happening is through an ongoing monitoring program and opportunities for more training.  Sure that means you will occasionally need to let Sally escape her cage at the front desk and take in a seminar, you’ll need to let Wendy view a webinar and give Nancy time to read payer newsletters (or even this blog!).  A few states have required CE’s for Chiropractic Assistants and while I’m not a fan of more rules and regulations, there is a tangible benefit in keeping your team up to speed.  After all, they may just be the one to save your hide.

The Sad Truth

As much as I hate to admit it, thanks to an ever-changing arsenal weapons designed to defeat you and your reimbursements, I do not believe any single strategy mentioned above is enough. To survive, thrive and win this battle, we are going to have to utilize bigger, better and more tools and use them more often. That’s the primary reason I created the Chiropractic Audit Armor service.  I highly recommend you consider it for your office.

Sales pitch aside, I will certainly admit that by no means do I think that’s the only way you can achieve a measure of safety.  In fact, I’m happy if this article motivates you to act in some way – however great or small, whatever format it takes, to improve and protect your business.

Your patients need you and we have a great profession we can’t let go just because the going is getting tough. In fact, who knows where the future will take us – it may get tougher still.  So, please act now!