Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 1153
Infrastructure 238 I

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

"Geico's Lawyers and Compliance Part 2"


Dr Studin: I'm back on with Dr. Bill Owens. So I want to finish up on our compliance issues with the lawyers from state farm and Geico. So my question to you is, from your experience, where do the carriers look the most to determine if you're compliant or not? And what are the biggest screw ups our doctors make?

Guest Doctor: Well, I think the first is the documentation as we mentioned in the first half, that's your communication with the insurance carrier on reimbursement.

Dr Studin: get specific, not just documentation.

Guest Doctor: specifically, on documentation?

Dr Studin: Yes. What pieces of documentation is being done inappropriately?

Guest Doctor: I think the number one is ENM reports, So your initial report and your reevaluation report, and this is why our profession historically, All of the consultants that have come out over the years had really positioned chiropractic from a Medicare perspective. And all, as you know, Medicare does not pay for ENM. So all the documentation for a Medicare claim from a chiropractic office is really in a soap format. And there's specific criteria to hit in there. But chiropractic as a profession is never been trained on what the CPT coding guidelines are for an ENM. So when an insurance carrier comes after a doctor, that's really all they have to look at is where is your initial report? Where are your orders? Every other health care profession is perfected ENM reporting except for Chiropractic. And that's also, I would think, is inherent in the EMR that we have our EMR is to generate assault note. So most doctors aren't even sat up in their office to even know whether they're compliant or not. But once that lid is off, now they can dig in further. Do you have an accurate diagnosis? Are you giving the same treatment plan to everybody? What about your time decode? What's your corporate organization? So I think the exposure, if every chiropractor in the United States get a compliant evaluation and management visit and documented that properly, 85% of all of our audit problems would go away, because there's no reason to dig. But that's the exposure.

Dr Studin: Listen I've always said that it's a hard mark rule on a soap note that for every era you touch, you need a symptom of clinical finding and a diagnosis there-in lies the problems of soap notes, and the soap note is a daily treatment note. Even though you can call that your initial value, you shouldn't, it's not really part of the ENM lexicon. And that really makes us an outlier in the healthcare community because no one else in the entire health care world caused an ENM encounter, which is your initial encounter, a reevaluation and 99202-203-204-205 and Etc. Those are your initial encounters in re-eval We are the only profession who calls it a soap note, and that's the problem. So in your soap note, which is your visit encounter not your evaluation and management. You need to have a symptom, diagnosis, the clinical findings for every area you touch. That's it.

Guest Doctor: Now mark you're right and you bring up a good point because if anybody listening to this has ever been audited because you were billing for three to four regions of a chiropractic adjustment when it really should have been one or two, that's the reason that comes up is because you're missing a diagnosis or a complaint or an objective finding for that other region of the spine.

Dr Studin: When I defended a doctor up in Massachusetts years ago, that's what he was brought down on, and they brought him into the Federal Rico, the racketeering act, and had a judgment against them for $1.65 million plus a quarter million-dollar legal fees. So that's what he was brought out on that very issue. The other issue when you brought it out, I see doctors are getting a little bit better on that, especially the new doctors coming in. But the second component that you talked about though is the ENM. It's the initial evaluation and reevaluation and like the conversation I had yesterday with his doctor in the state of Washington is youth. How did you get such bad habits? You've cut every corner you've learned in professional school; you were trained just like I was back in 1970’s/80’s to do an ENM did the requirements haven't changed in all these years. You're talking 40 years. The carriers will call the greed and the prosecutor will call it a felony and at the federal level, they call it Rico. So you know that there's no other reason than that. And that needs to be cleaned up yesterday. The thing is EMNT there's no T in an ENM code. There's no treatment in an evaluation and management report at 99203 and ect. There's no treatment put on there. That's on a separate soap note. You need your treatment orders and then you need a separate soap note. And for SONA you can say, refer to the initial evaluation and then you're fine. But the last thing I want to discuss your treatment orders. How many doctors just take x-rays without ordering though? Almost everybody. How many doctors given LSO belt without an order for it has to be not only an order, put a rationale, like give me an example of a rationale for anything that you're ordering. What would one of the macros say?

Guest Doctor: what is the macro say that I am ordering a series of cervical spine radiographs. And then you would list the views.

Dr Studin: Cervical, thoracic A and P, Lumbar, A P lateral and 12 lakes.

Guest Doctor: So you're putting in your order, what you're ordering. But then you're also talking about why you're ordering the x ray to assess the integrity of the bone and ligament structures of the cervical spine in relation to persistent cervical spine pain. We have a document, different series of these in the system. However, you need to discuss the details of what you're ordering and why, why is it medically necessary? And it can't just be because I decided that the patient told me it has to be in writing. So at any time you can deliver that to the insurance carrier, state board, all those things. And that's where your exposure is, it has to be written in the chart.

Dr Studin: One word over utilization.

Guest Doctor: Well that's the thing they go after even know your clinical rationale could be completely fine if you can't prove it and they can go back years.

Dr Studin: fraud has no statute of limitations.

Guest Doctor: So imagine being in practice for 40 years.

Dr Studin: you can go back 40 years on me if they suspect fraud, 40.

Guest Doctor: even if you were right, how much would that cost you to just to engage in a conversation to prove over 40 years that you did nothing wrong.

Dr Studin: $450 an hour for the lawyer and probably a federal court probably $650 an hour or $700 and weeks of my time away from my functioning in my world.

Guest Doctor: I'll tell you this from dealing with, as much as I deal with the medical community and academia and clinical practice medicine has gone through this years ago. Now, are there still instances where medical doctors get taken down? Of course, but now it's more 

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