Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. We suggest you watch the video while reading the transcript.
Hey, greetings friends. This is Sam Collins, the coding and billing expert for you for the chiropractic profession. Let’s make sure we have a good understanding of what happens when we get an audit. Request, what goes on? What should we do? How do we be prepared? I wanna make sure you can do this with some semblance of comfort, but also with preemptive ideas of things to prevent what’s going on.
So let’s go into the slides. Let’s talk about what do you do if you are audited? You know when you receive that dreaded letter, I don’t care who it’s from. It could be from a regular insurance, Medicare, or otherwise. The first thing I will say, always when you get an audit, do not panic. Often people get more upset.
Click here for the best Chiropractor Malpractice Insurance
It’s relax for a second. Think of it. You are a good provider. You’re giving good services to your patient. You’re doing so eloquently. You’re doing it with fairness. You’re doing it with your best practice. So first and foremost, don’t forget that. Do not [00:01:00] panic. What is someone looking for when they’re auditing?
Often it could just be random. It’s not something that they’re picking on you for, and simply an audit is just verifying. The services that were provided here would be the thing. Should you panic about something you bill for when you provided it? Realize audits often are not. About medical necessity. In fact, almost never.
Get a Quick Quote and See What You Can Save
Now, remember, I’m on the reimbursement and coding committee for Optum Health, and when we go through our yearly, one of the meetings anyway, on our yearly things, they talk about audits. Truthfully, they never get into medical necessity. What it’s always about is whether or not the services that we’re billed for and paid for.
We’re provided. So when you first get a request, don’t panic. Let’s read through it. Let’s see what’s going on. If you’re a network member with me, that’s the first thing you gotta do is call me. What are they requesting? Let’s look at what type of claim is it? Is it Medicare? For Medicare, if they’re requesting records for an audit, you know what they’re looking for.
Is there a subluxation? Is there manipulation to that direct area? That’s pretty much [00:02:00] it. So first think of what type of claim is it? What data are they asking? Are they asking for records? Are they asking for some other information? And what patient and or patients are they requesting from? Often begin the panic starts ’cause you think, oh my God, I’ve done something wrong.
Not necessarily not at all. You have to think of it’s what’s in your records. If they’re requesting records, if you will, or it’s auditing, they’re gonna look for what was on the claim and or paid for, and did you document it? Was it properly there? Realize it doesn’t have to be perfect, but just reasonable.
Now, keep in mind, there’s some things you wanna be mindful of that what can set off an audit. And I’m not panicky about audits at all. If you’ve worked with me at all, you’ll know I’m gonna be whoa, slow down here. However, there are things that can set you up for an audit, and it doesn’t mean it’s wrong, but it’s something to be prepared for.
So by example, if you drive a flashy Lamborghini, I would suspect you want to drive a little more calmly because your car’s [00:03:00] gonna show up more. So you don’t wanna be speeding around. Doesn’t mean that you’re speeding, but. The car’s appearance may be. So what’s one of the things that can happen in a chiropractic claim is if you are billing routinely, very high level e and m codes, could that set you up for more chance of an audit?
I would say it’s certainly what might get you looked at a little bit more. Why? Because if every single patient’s of a very high value, they’re gonna think what’s going on at this office? You never see someone with a simple problem. And certainly what if you work in a practice that you deal mostly with severe injuries?
You deal with post-surgical patients, you get referrals from that matter. Might you have a higher level of e and m codes? Absolutely. What if you bill more personal injury cases? So realize that doesn’t mean it’s incorrect. You just have to make sure, was it proper what I’m doing? Of course, what can set you up is billing an e and m code daily.
Every visit, we all know that you can’t do an e and m daily, not the coding, because there’s an embedded evaluation as part of the treatment. I had an office recently that got a request and [00:04:00] denial based on he was using 9 9 2 1 1 for his re-exams. Now, frankly, the reason that was audited, they’re like, what could you be doing with a 2 1 1 that’s so low?
Frankly, what we’re able to show is that actually he undercoded and so the audit is gonna help him get more money because he did not use the proper code. We’re gonna rebill with a 2 1 3 or a 2 1 4 ’cause he didn’t understand the value of it. Bottom line is billing things can get it set up because they’re looking for things that are oddities.
Realize AI. Algorithms, they’re looking for things that are unusual patterns. An unusual pattern might be routinely billing for four or more services per visit. There’s nothing wrong with billing for services. Four units, maybe six units in some instances. But if it’s for every patient all the time, that seems odd.
Now that doesn’t make it wrong. ’cause again, what if you deal with post-surgical patients and others, you just have to have reasoning behind it. Or that care is very long term and it begins to seem maybe that’s maintenance. You’ve been in treating a patient for a year and you’re treating ’em [00:05:00] every other week.
That might be something they wanna look at for necessity, maybe. How about just long-term care for something that seems uncomplicated? That again, doesn’t make it wrong. Maybe there’s a lot of flareups, but those are little things that’ll get you set up. But here’s one other one. I want you to be very mindful of.
Staff and patients. What if they feel something’s improper? It doesn’t make them right, but someone’s going to look. I had an office that had an issue of an employee that was disgruntled that they fired, and so she wanted to cut back and say they weren’t doing certain things. She was making up most of that.
It was no big deal. But bottom line is those are the types of things that can happen. So you wanna make sure, don’t put yourself in a compromising position. I have no issue with audit if you’re a network member with me. We get an audit, we win those nine outta 10 times. The reason why is the services provided and billed for were actually provided and documented.
So here’s something that comes up. Take a look at this. This is one where an insurance company is saying, Hey, we look like you’re billing. Something. Way above. You’ll notice the kind of reddish [00:06:00] orange is showing where they’re billing. The blue is where the expectations are. And you’ll notice here they’re billing a lot of patients.
In fact, basically 90% at 9 9 2 0 4. Now, does that seem ooh, that would be a little high, if you will. Now, I won’t say two oh fours. It’s two one fours as well. Is that gonna set you up for them to look? Sure. But what if you have patients that require that? This particularly was an office that dealt mostly exclusively with auto cases and particularly more severe ones.
They were on a referral source from a medical place for it so it would make sense because many of these patients were post-surgical and otherwise. So again, in this instance though, it was audited. Does it make it a big deal? Absolutely not. Here’s another one, and forget personal injury. Let’s talk about it from just a insurance standpoint, like a Blue Cross here from Highmark, and you’ll notice here it says, and I’ve circled it in red here.
It says, the outpatient submission them for an ongoing review. The purpose of identifying providers who are billing high level codes significantly more often than other providers. So it says, Ooh, you’re billing high level codes. What they’re saying is in this one, they’re billing a [00:07:00] lot of physical medicine, rehabilitation, exercise, in fact.
I recommend it and think you should, frankly, what? Patient can’t respond to some of that. So it says here in second paragraph. As a health plan, Highmark is responsible to its members at a group of customers. Ensure the best use of premium dollars. Highmark is an obligation of network providers to make aware of a claim submission issue identified.
They’re not saying that your billing is wrong. They’re making sure, Hey, this is something that’s higher. What’s the reasoning? What if you deal with a lot of rehab patients with neuromuscular skeletal issues do require exercise, would it be Absolutely a hundred percent? I would argue to some extent maybe.
But maybe not as much for some as others. Depends on what’s coming up with it as far as severity, but certainly not anything to panic. When you get this, you’re thinking, oh, maybe I better not bill for that. Absolutely not. If you provide and it’s necessary, I would, you’ll notice this comes from my United Healthcare meetings with Optum Health, and you’ll notice most of the issues here.
Illegible [00:08:00] documentation is not an issue. Service not documented, not big issue. Notice the big issue. Timed services. So one thing I’m gonna implore you is making sure that if you’re doing a time service, make sure it’s well documented. That’s mostly where we’re gonna lose. So I’m gonna say, take a moment.
I’m gonna use my Jerry McGuire theme here. Help me help you. Here’s a couple of quick things to do. Best practice for audit protection. Always think of this preemptively. We’re the services reasonable and necessary? Be careful if you say, I do every patient the same way, no matter what. Not every patient, maybe every patient with a certain type of condition.
I would agree. So make sure that all services build are documented by example. If you’re doing an e and m code, ensure that it’s based on the level. Is it medical decision making or is it gonna be time? Remember, an e and m code can be chosen by time, but also medical decision making. Remember someone with trauma.
Automatically qualifies for a 2 0 3. What about a person with only one complaint? That’s a 2 0 2, [00:09:00] but multiple complaints 2 0 3. So it can be more than just time. Of course, CMT codes make sure that you’re using the proper one. Your technique is not how you should choose your codes. If you do activator, that’s wonderful, but that doesn’t mean you get to bill a four two and a four three every time.
It’s gonna be based on the diagnosis. And what’s manipulated in combination. And then of course therapies give me the what, the where, the why, the application. In other words, put it in a way that someone can go, oh, I see it. You just can’t check off. I did exercise. What exercises, how many sets, how many reps?
And of course, how much time. Also, keep in mind, medical necessity may not be as. Typical, but I wanna be prepared for it. If they’re saying, why is it medically necessary, you’re gonna make it obvious. Use outcome assessment forms. Use some type because you can always show the patient improving. I will tell you, I’ve seen audits one on this simply because the notes weren’t great.
Now, notice I said they weren’t great. That doesn’t mean that they were failing, they [00:10:00] just weren’t as good as some others. Big deal. Remember, a C student still passes. It’s more about what’s the outcome? What is an insurance? What is the patient really looking for, is to get them better. Show me that.
Give me an outcome assessment that measures function, not just about pain. That will save you every time. And of course, good documentation, practices help ensure that your patients receive appropriate care. Okay. That way they know exactly what’s there, and ultimately make sure too, things like this was step, there’s no inducements, no kickbacks, things of that nature.
If there’s hardships, document it. Of course. And remember, if you’re using staff to do therapies. Most states, that’s perfectly fine. Some states are very liberal. You don’t even have to be in the office when it’s liberal. But some states require to be in the office. Some may even require the staff have specific training or licensure.
Just make sure you know your state so that way there’s not gonna be an issue of you supervising someone. I would say keep it this way though. Keep it simple. The achman razor simplest answer. I want to be able to read your notes and be able [00:11:00] to do what you’ve done. If you told me you want ultrasound to the knee.
I will say to you, that’s not adequate because what do you mean? What part of the knee is the patellar tendon? Quadriceps tendon medial collateral. Notice something as simple identify where, tell me the amount of energy that you’re using, 0.5. And then tell me how many minutes. Not complicated.
Think of it. Write it up in such a way that someone else can read it and go, oh, that’s what I want. You’re in a sense you’re writing a prescription. Now keep in mind though, before you panic as well, how many of you actually know about your coverage? I’m gonna point out ChiroSecure, and the reason I do this is because it’s a company that doesn’t settle.
It’s not just gonna give up on you, but it’s also something. Notice here, the supplemental defense, anywhere from 10 to a hundred thousand. Boards hipaa, but insurance audits, if you’re being audited, trust me, I’ve worked with them multiple times and with many attorneys, we mostly win, but you have to have some that’s defending you.
So if you’re running into an issue [00:12:00] you’re not sure, don’t be afraid to contact the carrier. They’ll put you in touch with someone like myself. That’ll make sure. Let’s review the notes, see what we have defensible. Realize we’re all here to support you. Check your malpractice. Probably don’t have this. This is one of the things I’ll say is excellent about this company and of course me at HJ Ross.
That’s why we do continued education. We do the network. If you’re a network member, you know what I do with you? Every year I audit files. I wanna make sure if there’s something we’re not doing correctly, let’s correct it. ’cause if we preemptively correct it, if they post audit, after that makes it go away.
Make sure audits are gonna happen. Don’t panic. We’re here to help you. Until next time, [00:13:00] [00:14:00] friends.
Click here for the best Chiropractor Malpractice Insurance
Get a Quick Quote and See What You Can Save