Academy of Chiropractic’s
Doctor's PI Program
From the Desk of:
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
This consultation is being offered to every organization that utilizes my services...It is that important!!
"S.O.A.P. - 4 Critical Standalone Letters"
I attended the New York Chiropractic Council's state convention this past weekend. This is an organization that I co-founded in 1989 and have been very active in since its inception, at various levels from member to president (executive board of directors) and most every other position. As a result of my participation, visibility and formally lecturing, I am known to most members statewide and my advice is often asked.
There are 2 types of advice that is sought. The first is publicly in groups of doctors or in lecture settings and the second is in a hallway where I am asked to go to a private area to have a confidential conversation. This past weekend was no different as I had multiple doctors corner me and ask for a "confidential meeting." During these meetings, the doctor would hand me a document request from either a licensure board, carrier or the government auditing the doctor and the doctor would ask me what he/she should do. At least those are the smart ones as many come to me after the process is underway and they have "shot themselves in the feet."
The main topic of private meetings this weekend were all the same; each doctor was being audited by either CMS (Center for Medicare Services) or private insurance companies that were demanding copies of S.O.A.P. notes and evaluations. In each instance, I had the doctor re-create for me his/her S.O.A.P. notes and evaluation so that I understood what he/she creates on a daily and monthly basis to better understand what he/she did. Although the S.O.A.P. notes were taken in various formats from travel cards to full written notes to electronic notes, they all had 1 critical flaw in the process. The problem is one of "standalone."
The advice I gave to the doctors was to look at their S.O.A.P. notes conglomerately and individually to ascertain the conditions of their patients. Here is the key. If you can look at an individual note and understand what is happening, then you are in great shape. If you have to go to previous S.O.A.P. notes and evaluations, then you are exposed to having big problems. For example, you cannot write in the subjective, such as "see previous note" or "improved from last visit." This does not give a story and that is what's required.
There are many level of audits and a simple letter from a carrier requesting 1 or 2 visit notes is a probing inquiry to see if you warrant a surprise inspection from the Office of Inspector General from Medicare or the SIU (special investigative unit) from private insurance companies or a subsequent request for every record of every patient for a particular carrier. Some of you might feel invincible and that your notes are perfect or that you are a healer and based upon your clinical results, you are bulletproof. Here is the reality. If the carrier wants to audit your records, by law they can and there is nothing you can do at the end of the day to prevent it. There are some states, like New York, that limit a carrier to 3 years in retrospectively auditing a doctor's notes. However, if the carrier suspects fraud, there are no limitations. This is the legal mechanism that all carriers use. They always suspect fraud and it is the easiest step to take when wanting to leverage a doctor to get their money back.
The carrier simply hires a doctor with credentials like mine or someone similar and pays him/her a lot of money to say that all of your care, from the beginning of your practice, was not clinically indicated. You might think that inflammatory; it isn't. I have been retained by many lawyers representing doctors in legal battles because they either didn't heed my advice or they put themselves in a position to lose. As a result, I have, through subpoena power, been given all of the internal documents to review form the carriers, giving me a unique perspective of how the carriers "get away" with making such inflammatory claims and selling it to the courts.
Will all of these claims bear out after a long, bitter protracted trial? Of course not, but the carriers aren't using them for that purpose. They are used for leverage against you and the carriers are succeeding in getting that leverage against you in the form of legal turf. That turf is getting a case certified for RICO antitrust putting you in federal court with a more expensive lawyer, having you face treble damages, forcing you to produce massive amounts of documentation and having legal standing to stop paying your current and future claims that they know you will eventually forfeit.
Are you starting to get the picture? In the past, I have strongly advised you to get a voluntary audit with me, and many have heeded the advice and sleep much better knowing that they are doing it right, while others have all of the answers and remain targets.
Getting back to the subject at hand, your S.O.A.P. note. Each note must be a standalone document. When the carrier audits 1 visit, they must see what is going on in that individual S.O.A.P. note. You must have the specific region well-documented to give reason to care for that region. There must be a subjective reason for caring for the patient with objective findings and assessments for each individual reason.
The only area that is acceptable for citing previous notes is the care plan. It is here that you can cite "follow ordered plan" and it must be documented on the most recent evaluation or re-evaluation. It is for that reason that auditors request both the documentation for the specific visit date and the evaluation associated with that visit. Medicare clearly states that evaluations "MUST" be performed every 30 days and unless an individual carrier or state regulation alters that, that is your standard of care.
Many will argue that their patients only come once per month and my response is, "Does that fall within the 30 days or not?" You must re-evaluate your patient every 30 days, not every 12 visits, or 8 visits or 1 visit. The level of evaluation you perform (99215, 99214, 99213, 99212) is based upon clinical necessity and you get to determine that. Just ensure that your documentation certifies the level of evaluation you coded. If you need help with forms, go to:http://lawyerspiprogram.com/index.php/forms-a-templates
If you feel this process absurd, silly, stupid, or a waste of your time, then you are much smarter than I am because these are the rules and standards of our licenses. I am dumb enough to know to follow the rules as long as I want to stay in the game. I didn't create the game of being a licensed chiropractor, but I like it and want to stay in it while earning a living for rendering quality care. Follow the rules!