Getting Paid on Insurance is Easy
I am working with the lawyers for a doctor who is fighting for his license. The insurance company reported a license violation to the chiropractic state board that, by regulation, requires an investigation. The lawyer first contacted me on January 15, 2019, so when reading this you will have a reference date. Upon first glance, the state board felt it was a credible complaint and hired an independent expert to critique the doctor’s files.
The carriers take this route in order to make claims that your services were not within the standard of your license and be able to recoup all of the fees paid to you for your care.
Here are the preliminary findings and subsequent formal complaints against the doctor:
1. Treating without orders
2. Treating undiagnosed areas
3. Improper reporting of treatment
Let’s break it down. First, treating without orders. The doctor failed to perform a re-evaluation in a timely basis. He did not perform a re-evaluation every 30-45 days and kept treating for 70-90 days successively. There were no updated orders in the SOAP notes that could be construed as further treatment orders based on any clinical findings. Second, treating undiagnosed areas. The doctor treated the thoracic spine with no thoracic diagnosis or orders to adjust the thoracic spine. Third, improper reporting of treatment. When performing ultrasound, the doctor did not list the frequency settings that were applied to the patient.
This particular state is seeking to suspend the doctor’s license for 3 years as a result of these infractions. Fair or not, the doctor has hired a health care lawyer for $450 per hour to fight these charges and the lawyer reached out to me to support the doctor’s case. The doctor has to pay a chiropractic expert to certify his care as reasonable as well. The final disposition of the case will not be had for a minimum of 1 year, maybe 2. Let’s be clear; the doctor has to pay a lawyer for 2 years over apparent minor issues.
These apparent minor issues are not MINOR. Reporting is serious stuff and the function of state boards is to protect the public. Your notes are critical in the care of patients which goes beyond the insurance company’s desire to find a wedge to get you to repay all of their fees. In protecting the public, if you treat undiagnosed areas, have you fully examined the treated area and concluded a diagnosis prior to delivering a high velocity thrust into the area? Have you documented the frequency of ultrasound correctly? What if the patient goes to another doctor because your ultrasound treatment hurt the patient and the new doctor does not know the frequency used and repeatedly hurts the patient. This could have been avoided if you documented the care you rendered.
These are issues state boards consider when reviewing charts and the current climate is to make examples out of offending doctors so that the message is clear to the rest of the doctors. State boards have limited resources due to budgetary cutbacks so that when the board gets a doctor to act upon, they are not as lenient as they once were (my personal opinion).
This particular doctor has one very big thing going for him. The carriers are looking at a 2006 case and the doctor voluntarily had a compliance audit in 2018. Since that time, the doctor’s attorney will be showing a progression of improvement in documented notes since the voluntary audit. Will that exonerate the doctor from the 2016 errors? No. However, it will potentially have the doctor placed on probation vs. losing his license for 3 years. That is the legal strategy. Time will tell what the final verdict will be.
The moral of the story is very simple:
1. Evaluate your patients every 30-45 days
2. Evaluate and diagnose every region you touch
3. Document your care completely
4. Get a voluntary compliance audit
Insurance carriers are looking at every area to be able to reclaim their money and many of you are easy targets. In fact, the Office of Inspector General (Medicare) had announced earlier this year that they are tripling the number of independent auditors to look at as many doctors as possible. We are big business and easy game and many carriers have followed the lead of the Federal Government.
The solution is simple, bill and code accurately and document to the standard of your license in order to keep everything you have earned.
THE MORAL OF THE STORY FOR MY CLIENTS, GET A VOLUNTARY AUDIT FROM ME as per the welcome email... ASAP
I DO NOT WANT TO SAY, "I TOLD YOU SO."