The #1 Issue to Prevent or Prevail in an Audit

The #1 Issues to Prevent or Prevail in an Insurance Audit

by

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

This is a easy as it gets because you already know everything you need to avoid audits and prevail in the most difficult ones. I get calls weekly from doctors nationally who are involved in insurance audits and most of them are writing big checks to the carriers for one reason. That reason, surprisingly enough, is not because the carriers are functioning illegally or underhandedly, it is because they are practicing aggressive business policies knowing that doctors are usually lazy and neglectful in their documentation. Our lack of attention to detail is driving the carriers' profits up, at our own expense, and we have no one to blame but ourselves.

First, let's define a retrospective audit.  In our case,  It is a review of a doctor's records after the carrier has paid him/her and gives the carrier an opportunity to demand back all of the money they paid the doctor, with interest. If they find the doctor has poor records, they can charge him/her under Federal RICO, resulting in treble damages (3 times what they paid the doctor) and force the doctor to go to federal court with legal fees upwards of $800 per hour. That is the leverage they use to get the doctor to settle for big $$$$$.

I have been retained by lawyers in the past who represented doctors that had been retrospectively audited. As a result, I have been been able to see, through the power of a subpoena, the internal documents of the insurance companies and what they look for in retrospectively auditing a doctor, specifically a chiropractor. The formula is quite simple and if you follow it, you should have no problem. First, you have to abide by a few very simple rules.

Rule #1: NO TRAVEL CARDS. This is nonnegotiable. According to the president of the insurance company lawyers association in 2009, chiropractors with travel cards are the #1 target for retrospective audits. The reason, those doctors are the easiest way, statistically, for the carriers to get their money back from any doctor. Travel cards do not meet most standards of your license. Even if you have coded, and shorthanded the travel cards, you are a target and you will spend tens of thousands of dollars in legal defense proving that. Therefore, you lose even if you win.

Rule #2: You must have a diagnosis for every region of the spine that you touch. How can you treat an undiagnosed area? The thoracic spine is a prime area that causes the downfall of many in a retrospective audit.

Rule #3: For every treatment, you MUST have a SOAP for each region, meaning a positive finding during each visit justifying the necessity for care.

Rule #4: A formal re-evaluation every 30-45 days. There are no exceptions during active care.

If you follow these four rules, you will begin to create a bulletproof environment that will allow you to keep your hard-earned money. I also employed the practice of sending in my evaluation reports and SOAP notes, understanding that it was expensive and I killed a few trees, but resulting in my not being audited. I mean sincerely that I was audited monthly by different carriers, but once I sent in the notes, there was nothing for them to audit, as they had everything up front. Life became much easier.

RULE #5: Get a voluntary audit of your own. Dr. Michael Schonfeld, 516-695-7732 (chirodoc006@gmail.com), is a chiropractor who has vast experience in auditing chiropractic charts and charges $500 for a complete audit review. It is the BEST money you can spend to learn how to bulletproof yourself. He does not work with doctors who are currently undergoing audits. His specialty is to teach you how to prevent them. I strongly endorse him.