PREVENTING INSURANCE AUDITS AND RETROSPECTIVE REVIEW

How to Keep you Money

By Michael Schonfeld DC, DABCO

www.cmcsmanagement.com/db/audit.php

You are opening the mail with the glee of a 9-year old on his birthday waiting for the checks to “pop out of the envelopes” from friends and family when you see a very thin envelope from an insurance company that insures many of your patients. The letter inside asks you to send them copies of charts for the 63 patients they have paid you over the last 5 years and then gives you a reasonable deadline to comply. In the interim, they inform you they are will no longer pay your future claims until their audit is complete.

You think nothing much at the time, only that your gleeful mood has changed and you proceed to call 5 friends to see if they have had a similar experience. Realizing that you are a healer and have done nothing wrong, you hastily copy your files and send them to the carrier wanting the current claims to be paid. Months go by and you hear nothing and forget about the audit only adding up how much they now owe you in back claims pending the audit.

One day, you are back in your gleeful mood opening the mail and the same type of envelope comes from the carrier and you decide to open it last with much anxiety. After reading through the letter, the carrier is demanding repayment of 100% of the money paid for those 63 claims over 5 years totaling $242,802 and refuses to pay you the $86,900 they currently owe you citing fraudulent billing practices.

In addition, if you do not pay the full amount with 30 days, they will commence legal action against you with civil charges, possible civil RICO and possible criminal charges.

If this sounds inflammatory, it is not. In fact, this type of story is occurring in chiropractor’s office nationally and many on a larger scale. I am not talking about the doctors who commit blatant fraud; I am talking about the honest ones who simply do not document properly.

It’s the little things that will get you; such as doing a complete evaluation like the one we are all taught to do in professional school, formulating a diagnosis for every area that you treat. Creating an accurate diagnosis, prognosis and treatment plan based upon positive clinical findings. Maintaining full SOAP notes and ridding you of that “bulls-eye;” the chiropractic “travel card.”

The insurers are getting smarter and want to increase their corporate profits and you are their “golden goose.” You are the easiest way for them to make windfall profits and it has nothing to do with your ability to get patients well; it is about how poorly we as a profession document.

Remember the old adage, “It’s not about what you say or do, it’s about what you write down.” If you want to keep your money, document correctly.

Over the last 30 years I have been perfecting and reviewing the documentation for practices and I have come to understand how easy it is for the carriers to get their money back. In performing charting audits for doctors nationally, once the doctor sees the shortfalls of their charts, it is an easy process to correct if the doctor is motivated. That motivation is the easiest part!

Correcting your documentation does not forgive you for past regressions; however moving forward with “clean charts” reduces your exposure to being audited. An internal audit ordered and performed by yourself is the least expensive and least painful way to fix those problems and I urge you to do so immediately.

Internal chart audits start at $500, which is a fraction of what the carrier will ocst, even if you have done no wrong.

In today’s environment, it is not a matter of “IF” the carrier is going to come; it’s a matter of “WHEN.” Be pro-active and work on creating a BULETPROOF practice.

Dr. Michael Schonfeld is a compliance auditing specialist and can be found at www.cmcsmanagement.com/db/audit.php or can be reached directly at 516-695-7732