Academy of Chiropractic’s


Lawyers PI Program

#83

 From the Desk of:
 Mark Studin DC, FASBE (C), DAAPM, DAAMLP
 
 “Insurance Audits:
 Tactics Revealed”
 
URGENT- MUST READ
 
 
I just received a call from a doctor who had a licensure complaint against him from an insurance company. While this is not new, if you put the pieces of the puzzle together, the tactics of the carriers are becoming clearer and create a more urgent message.
 
 
2 years ago, in the same state with the same carriers, I was retained by a lawyer to represent a doctor who was retrospectively audited and subsequently sued in a Federal RICO civil suit. The carrier was requesting that every penny be refunded from this solo practitioner who was in practice for 7 years. This doctor had 10 patients a year from this carrier, actually 72 in total, equaling approximately $550,00 in payments over the 10 years. The carrier was requesting the full amount back, plus interest and treble damages, because it was a Federal RICO case. The total was approximately $1,650,000 plus legal fees. The doctor, having felt he did nothing wrong, fought the case and I was brought in to certify his records as compliant and usual and customary with chiropractic practice and billing standards.
 
 
On another case, I was given all of the insurance company’s internal auditing documentation, including the carrier's chiropractor they paid to certify the doctor's records as non-compliant. Part of the records related to a licensure hearing that the carrier had instituted a year prior and that same doctor working for the insurance company was the doctor they cited in the licensure complaint, stating the doctor did not comply with his licensure standards. 2 years prior, that doctor had been found to be in compliance with his licensure standards, but in the proceedings the carriers were able to garner a lot of information about the doctor they normally would have no access to in a civil suit. The carriers utilized that information as the basis for their Federal RICO case. The doctor fought and based on nonsensical technicalities and the testimony of the former board member, the doctor settled, paying over $300,000, $75,000 in legal fees and the rest to the carrier in spite of his providing quality healthcare as billed.
 
 
The game has changed and the stakes have gotten much higher. The Federal Government has decreed that the government is stepping up their efforts in rooting out fraud and every carrier is getting much bolder as a result, realizing that with that decree, the courts will lean towards the insurer. This is not a political statement, as I applaud any effort to reform the insurance system as the carriers have been laughing all the way to the bank for decades, but...there will be growing pains in that reform and we have to be wary of tactics and be pro-active in doing it not just right, but as close to bulletproof as possible.
 
 
One huge step I have been saying from the day we met is to ensure you get a compliance audit by me. That is non-negotiable, and must be done YESTERDAY if you haven't yet. 
 
 
Secondly, You must become Trauma Qualified and get on the Trauma Team to list your name nationally. This will give you the credentials to learn more about both what to do and what NOT TO DO. Beyond the medical knowledge, it helps you understand compliance, documentation and how to function more compliantly in practice. 
 
 
The point is, in order to be bulletproof in today’s marketplace, you must have the credentials behind you, not just your knowledge and your DC is no longer enough. We are no different than the medical profession, which is why specialties exist. Everyone is being judged equally.
 
 
The state licensure board of the doctor that called this morning is requesting a copy of the doctor’s curriculum vitae to determine if he is credentialed in caring for the patients he cared for. This is another huge reason for you to have your CV in order and updated regularly. We have given you, on the US Chiropractic Directory, the only place on earth for a chiropractor to create an admissible CV. Have you completed your CV online? Perhaps if this doctor had a CV and it was posted on the US Chiropractic Directory, the carriers would have seen his credentials and not gone after him. Being invisible makes you a very viable target and no matter how large or small your practice, you are a target.
 
 
The name of the game is money, your money and the carriers are after it with the stakes in the $Billions$. Bulletproof your practice, yourself and your family. Take the steps I have outlined and be pro-active.