Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 32 CA
Part 1 "Prevail in Any Audit"
The #1 reason doctors get audited and win or lose an audit comes down to one simple word: DOCUMENTATION. This sounds very easy, oversimplified and probably a little Pollyannaish in explanation. Truthfully, if someone said that to me, I would probably not even hear it. It would be like "white noise" or the instructions the stewardess gives you prior to any flight. Who listens?
When the plane is going down, everyone always wished they had listened! Being audited is a frequent process, unlike a plane crashing which virtually never happens. You need to be prepared in order to both prevent and prevail in an audit.
This morning, I taught a class at the University of Bridgeport College of Chiropractic to entering interns getting ready to see patients for the first time. I shared with them the story of the 7 year practitioner who lost a case to Encompass for $1,875,000.00 because he didn't document every area that he touched (more on that in a moment). I explained to the "wide-eyed" students that there are really STUPID doctors in the field that are currently treating and do not follow what they learned in school. The federal government understands this as they increased the auditors at the federal level 4-fold because it is a money maker for the government. Every insurance company has followed suit; they want in on the profit. Oh...by the way...you are their "cash cow" or "profit center."
The message I gave to the students in the class was as follows:
For every area you touch, you need a reason to treat that area, whether it is a symptom or underlying issue, clinical findings and a diagnosis. Without all three areas handled for EVERY SINGLE ENCOUNTER, do not touch. No different than all of us learned in school and unfortunately, too many forgot when they handed us our diplomas and licenses.
Should you have that covered on every visit, you will never lose an audit. That is the #1 reason doctors lose in audits (along with not re-evaluating every 30-45 days during active care). This was also the reason for the doctor's loss to Encompass for $1,875,000.00. His documentation had holes in clinical findings and diagnosis on selected body parts. Meaning, he treated multiple areas and not all areas treated had a clinical evaluation, findings or diagnosis. This is a very simple equation and something we all learned in our professional training.
Part 2 "Never Get Audited"
There is one foolproof way to never get audited:
With every claim, send in the documentation for that service. Initial evaluation, SOAP notes, x-ray report, re-evaluation, etc. For every line item on the HCFA, send the corresponding note. If the carrier already has your documentation, what are they going to audit you for? Once we started doing that, we stopped getting harassed by the carriers and our audit requests simply STOPPED. Oh...our reimbursements increased instantly. We removed the major reason to delay our payments, the carriers not understanding what we did or why. The carriers had the "audit-able information" they would request in their hands up front and, therefore, had to pay. This doesn't mean that all paid right away as we know that some carriers could give a "rat's ass" about any rules and simply won't pay no matter what is in their hands...but the bottom line...our collections increased once we instituted that step.