Under an Insurer’s Microscope
COMPLIANCE
Kathy Mills Chang
MCS-P, CCPC, CCCA
One of the treacheries of health care is audits and recoupments. While certainly a percentage of chiropractic practices take the proactive approach and implement policy, training, and action steps to minimize the risk of billing and documentation-related errors, unfortunately, they are in the minority. Most practices assume the “under the radar” role or the reactive approach, which is dealing with an audit-related situation as it occurs.
There simply is no “under the radar.” If you’re in practice, you have professional responsibilities to maintain compliance in documentation, coding, and billing. Yes, even cash-based practices! Sadly, the reactive approach to handling these audit scenarios tends to be much more stressful and costly. In today’s world, a typical practice’s ability to confidently appeal and combat audits and recoupments is minimal. The reason? Many of these practices have inadequate documentation or inappropriate coding, thereby not providing the proverbial leg to stand on.
Would it surprise you to know that compliance guidelines require practices to conduct (or have conducted) a comprehensive self-audit at least once a year? Eye rolling aside, most providers find that there is a huge advantage for the practice to do so. Executing this self-audit enables the practice to find and fix errors before they make it to the processing systems or desk of a third party! Who
"Sadly, the reactive approach to handling these audit scenarios tends to be much more stressful and costly."
wouldn’t want to take this protected and preventative step for their practice?
When surveyed, only about 30% of practices feel adequately equipped with the tools and knowledge to competently conduct a self-audit of charts, compliance, and other practices. If your practice is counted among that number, add this task to your calendar and be accountable for ensuring the job gets done. Not only will this action prevent errors, but it will also contribute to finding and correcting mistakes before they become a long-term (and costly) problem. Documentation reviews and other selfauditing activities are an amazing educational, training, and communications tool that you have at your fingertips.
If you are among the 70% who feel unequipped to conduct your own self-audits and chart reviews, take advantage of the professional resources that do just that every single day. An internal chart review is ideal, but an
extra set of outside eyes prevents “going blind” to your own issues. A third-party review in a safe environment is more amenable than a third-party review in the middle of an audit. An experienced, separate set of “good-guy” eyes can be a beautiful thing when it comes to auditing documentation and coding. Here’s a look at how outsourcing these ever-so-important chart reviews can be extremely advantageous to you:
• In the world of documentation and coding, there is never a good time to make a guess. If you don’t know what you don’t know, how can you selfaudit? If you don’t know what to look for, what to compare against, or how to do it, you need that experienced, external set of auditing eyes on your side.
• You already know what your documentation says (or rather, what you think it says). Even the best CA is often trained only on the mechanics of the practice and may easily overlook a glaring error. An experienced auditor knows what to look for and how to help you meet medical necessity guidelines as well as documentation requirements.
• Outsourced audit professionals are often certified in auditing and can train you in better documentation while pointing out potential risks and unnecessary exposure.
• Most chiropractic offices (along with healthcare offices in general) simply lack the specialized knowledge to really scour your documentation, billing, and related aspects with a fine-toothed comb. You have your specialty and your expertise. It’s important to know the limitations of the practice and understand the value of outsourcing to specific professional services that know their specialty and expertise as well.
With a trained eye, the most common documentation and coding errors in chiropractic are often an easy catch. Sometimes, just reviewing a single claim form can begin to raise eyebrows. However, in other cases, it may take several documented visits to reveal suspicious patterns that may bring unwanted attention from a third-party payer. Often, unsuspecting practices are “under review” for months at a time before they’re even made aware that the simple records requests on patients are actually trying to build a case.
Patient records aren’t the only thing that can call attention to your practice. Billing patterns, use of diagnosis codes, and other issues that show up on the 1500 billing form can also be a red flag. When the insurer comes calling, it is your responsibility to have adequate documentation to support your claims and respond accordingly to third-party findings, i.e., denials, requests for refund, etc. At this point, it feels like quicksand. Inadequate documentation may result in a weak appeal or perhaps even raise concern about whether the practice should appeal at all. After all, your documentation can be your saving grace, or it can open a fresh can of worms for you and your practice.
Remember, it isn’t “if’ but rather “when” your practice will find itself in some type of audit, records request, or request for refund. The best advice is to take notice of the Howard Huff quote “it wasn’t raining when Noah built the arc” and take proactive steps starting today to ensure you have supreme confidence in your coding, billing, and documentation. Start now by conducting a comprehensive chart review for your practice or reach out to certified professionals who can give you a safe, “white-hat” review of your documentation. Could you be under the microscope now?
Kathy Mills Chang is a Certified Medical C.omplia nee Specialist (MCS-P). Certified Chiropractic Professi°nal Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 30 at KMC University and is known as one of our profession s foremost experts on Medicare, documentation and CA development. She or any of her team members can be reached at (855) 832-6562 or infold),KMCUniversity.com
