Gone Fishin’ : Why You Might Be an Insurer’s Favorite Pond
RISK MANAGEMENT
Kathy Mills Chang
A doctor called us using the kind of pressured speech and fevered pitch we recognize as the sound of someone in trouble. He’d received records requests from his local BlueCross BlueShield (BCBS) and the records he sent in didn’t pass muster. BCBS immediately upped the ante by asking for multiple records. Those were filled with errors too. By the time he called us, he’d been audited, and 47 of the 50 audited charts were either in error or incomplete. He’s now facing a deeper probe of 120 charts.
First, this crisis isn’t unique to BCBS, his state, or this particular doctor. Medicare and private insurers all over the country ai e sending out records requests at an unprecedented rate. Why? Because they’ve learned that up to 94% of all chiropractic documentation is in error, and a review will likely allow them to recoup a significant amount of money. We are, so to speak, their “cash cows.”
Second, when you receive multiple records requests, and certainly by the time you’re facing an audit, then you shouldn’t try to handle this on your own. Think about it. If the 1RS audited you personally, then you probably wouldn’t face them down by yourself. You’d want a tax professional by your side—either your tax attorney, your CPA, or both.
Why does it matter so much to have a professional help you?
• You can’t know what you don’t know. Most common docu-
mentation errors aren’t due to typos or not bothering to do it right. Ifyou don’t know what you’re doing wrong, don’t find out the hard way via an audit. Get on top of what’s required for clear, complete documentation before you’re in hot water.
• There’s actually a right way and a wrong way to respond to even simple records requests. You want to present the documentation in a certain order and accompany it with written clarification so that what you’re sending in tells as clear a story of medical necessity and episodic care as possible. Remember, never completely edit or add to a record when you’re preparing for the request. Ifyou must add something, a simple addendum is appropriate, but be prepared to explain why you added it after the fact if you’re questioned about it.
• When properly managed, a response to records requests can end the whole thing right there, long before things escalate into a full-blown audit. You want them to say, “You’re not the droids we’re looking for!”
• Learn whether this is a random fishing expedition or whether you have a pattern of coding and documentation behavior that raises and waves red flags. Many insurers randomly reject as many as 25% of claims just because they know most chiropractors won’t appeal. Similarly, records requests can be equally random. With a 94% error rate, the odds are good that a records request will show enough mistakes to justify further action. On the other hand—and this is vital to know—you may be engaging in behavior that puts you at much higher risk, such as underand overcoding, overreliance on a particular code, missing fields including (duh!) doctor signature, or documentation that doesn’t support medical necessity.
When someone calls us before there’s a problem, we can be proactive. Much like a third-party auditor, we can review the charts and look for documentation errors, coding blunders, and compliance concerns. Then, we can deliver a written report offindings with suggested coll ections before Medicare or a private insurer ever puts your documentation under a magnifying glass.
Doctors like our frazzled friend need, want, and deserve help, just as most of us would if we found ourselves summoned by the 1RS. It’s vital to fill out case summary templates correctly for resubmitting records, and in such a way that clarifies and justifies medical necessity and the codes chosen. Furthermore, increased records requests aie a sign that something is consistently wrong in your documentation. An analysis of sample charts, or even a deep dive into the entire practice’s procedures, policies, and documentation practices, is a great way to get to the bottom of what has gone awry.
When you don’t know what you don’t know, there’s very little you can do about it. The problem, for many doctors as well as people in general, is that we get weirdly comfortable and feel a false sense of safety by willingly keeping ourselves in the dark. It isn’t fun to find out things aren’t working well in your practice, but it most definitely beats the alternative, which is having an auditor find out first.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and W / "»1 Certified Chiropractic Professional Coder (CCPC). Since 1983, she’s been providing chiropractors with reimbursement and compliance training, analysis, and tools to help practices increase revenue and decrease risk. Kathy leads a team of ' 14 at KMC University, and is known as one of our profession ’s foremost experts on Medicare. She or any of her team members can be reached at (855) 832-6562, at http://kmcimiversity.com, or by emailing infodfikmcuniversity.com.
