Insurance Audits: Tactics Revealed

 From the Desk of:

 Mark Studin DC, FASBE (C), DAAPM, DAAMLP

 

 “Insurance Audits:

 Tactics Revealed”

 

 

I just received a call from a doctor who just had a licensure complaint against him from an insurance company. While this is not new, if you put the pieces of the puzzle together the tactics of the carriers are becoming clearer and creates a more urgent message.

 

2 years ago, in the same state with the same carriers, I was retained by a lawyer to represent a doctor who was retrospectively audited and subsequently sued in a Federal RICO civil suit. The carrier was requesting that every penny be refunded from this solo practitioner who was in practice for 7 years. This doctor had 10 patients a year from this carrier, actually 72 in total equaling approximately $250,000 in payments over the 10 years. The carrier was requesting the full amount back, plus interest and treble damages because it was a Federal Rico case.

 

The total was approximately $1,000,000 including legal fees. The doctor having felt he did nothing wrong, fought the case and I was brought in to certify his records as compliant and usual and customary with chiropractic practice and billing standards.

 

As expert, I was given all of the insurance company’s internal auditing documentation including the chiropractor that they paid to certify his records as non-compliant.

 

Part of the records was a licensure hearing that the carrier instituted a year prior and that same doctor working for the insurance company was the doctor they cited in the licensure complaint stating the doctor did not comply with his licensure standards.

 

That doctor 2 years ago was found to be in compliance with his licensure standards, but in the proceedings the carriers were able to garner a lot of information about the doctor they normally would have no access to in a civil suit.

 

The carriers utilized that information as the basis for their Federal RICO case. In that case, the doctor fought and based on nonsensical technicalities, the doctor settled paying over $300,000; $75,000 in legal fees and the rest to the carrier in spite of him providing quality healthcare as billed.

 

In my phone call this morning, the carrier made complaints against the doctor’s license, similar to the last case as they are now setting the doctor up for a RICO case to get their money back.

 

The doctor was frantic because this case was not about necessary care, but his credentials. The carrier’s complaint was that the doctor wasn’t credentialed in the type of cases he was handling. They were trauma cases and they are claiming that his DC was not enough. The doctor thankfully had taken continuing education courses in MRI and trauma related care from the www.teachdoctors.com site and now he is gathering documentation that he has taken courses in caring for children as that is also part of the complaint.

 

The game has changed and the stakes have gotten much higher. Presided Obama has decreed that the Federal Government is stepping up their efforts in rooting out fraud and every carrier is getting much bolder as a result realizing that with that decree, the courts will lean towards the insurer.

 

This is not a political statement as I applaud any effort to reform the insurance system as the carriers have been laughing all the way to the bank for decades. But...there will be growing pains in that reform and we have to be wary of tactics and be pro-active in doing it not just right, but as close to bulletproof as possible.

 

One huge step I have been advocating for years is to have an internal voluntary audit. Go to www.TeachChiros.com, the Academy of Chiropractic’s Web site (formerly CMCS Management, Inc.) and click on “Compliance Audit.” It is an invitation for Dr. Michael Schonfeld to perform and internal audit. His fee is $500 and you get more than you pay for. For a federal lawyer to defend you in a RICO case costs upwards of $800 per hour. This will be the best money you ever spend and I urge you to spend it there first and right now without delay.

 

I get too many calls saying that the doctor should have taken my advice years ago and they are paying $100,000’s and that is not inflammatory.

 

Secondly, if you treat trauma cases, take the PI Bootcamp found at www.TeachDoctors.com as it will give you the credentials and knowledge base for caring for trauma victims. If you are reading MRI’s take the MRI Spine Interpretation course found at www.TeachDoctors.com, if you care for children, take courses from the International Chiropractic Pediatric Association found at http://icpa4kids.com/index.php or other formal courses.

 

The point is, in order to be bulletproof in today’s marketplace; you must have the credentials behind you, not just your knowledge and your DC is no longer enough. We are no different than the medical profession, which is why specialties exist. Everyone is being judged equally.

 

The state licensure board of the doctor that called this morning is requesting a copy of the doctor’s curriculum vitae to determine if he is credentialed in caring for the patients he cared for. This is another huge reason for you to have your CV in order and updated regularly. We have given you, on the US Chiropractic Directory, the only place on earth to create an admissible CV.

 

Have you completed your CV on-line? Perhaps if this doctor had a CV and it was posted on the US Chiropractic Directory, the carriers would have seen his credentials and not gone after him. Being invisible makes you a very viable target and no matter how large or small your practice, you are a target.

 

The name of the game is money; your money and the carriers are after it with the stakes in the $Billions$. Bulletproof your practice, yourself and your family. Take the steps I have outlined and be pro-active.