Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 18

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.

"The Latest Threat to Your Practice, The Office of Inspector General (OIG) & Your Documentation"

In 2000-2001, I traveled around the country lecturing on HIPAA, Medicare and the Office of Inspector General (OIG). The OIG is the disciplinary arm of the Federal Government and the Medicare program to investigate fraud. How they work is by coming into your office, requesting 10 records (or some arbitrary number) and making a determination that if 4 out 10 have a defect, they then have the legal right to say that 40% of all of your records from your first day in the Medicare program is improper. It further gives them the right to request back from you 40% of everything paid to you from day 1 of your inclusion into the program, as well as penalty and interest, similar to the Internal Revenue Service.


Do you have that warm, fuzzy feeling yet?


Back in October, 2007, in Quickie Consult #3, I shared with you that doctors were being brought in front of disciplinary boards and sued by insurance companies for poor documentation. Here is what I wrote:


...I am hearing more and more insurance companies and patients alike, turning doctors into the State Disciplinary Boards for investigation (2 just today). Patients turn doctors in because they are mad at something and insurance companies go after doctors because they do not want to pay, and a ruling against a doctor gives them a legal reason not to pay and to recoup money spent!



The solution is documentation. No matter what a patient or carrier complain about, if you have documented your care according to the standard of your license, you can put your head on your pillow at night and go to sleep. Unfortunately, many doctors nationwide are too lazy to document a full examination and a SOAP note each visit and think they will get away with it. I get too many calls from doctors nationwide that thought the same and now spend too many sleepless nights worrying about their license and are forced to pay $10,000's in legal fees to protect themselves. Understand that your malpractice company does not cover insurance fraud issues and billing for something that is not reflected in your notes is considered fraud. Today’s message is the same as back in October.


In this week’s Chiropractic Economics, they report that the OIG is now targeting the chiropractic community as their investigation in 2005 found that 40% of the doctors were not in compliance with the guidelines for reimbursement.Chiropractic is a focus in 2008 for the OIG to investigate. Wellness is not a reimbursable condition and unless you have your patients findings well documented, you are exposed to the OIG’s non-compliance policies and it will cost you dearly. Medicare says that your patient “shall be re-evaluated every 30 days” not “should be,” therefore you must re-evaluate your patients monthly documenting positive clinical findings. In the absence of those findings, your patients should be dismissed from active care and the Medicare program should not be billed. If you do, then you will be considered billing the Medicare program for maintenance and that is not a reimbursable condition. When Medicare states that 40% of the claims investigated were fraudulent, they were not referring to the true condition of the patient, only the condition of the patient in the presence or absence of the findings documented on the evaluations.


Over the past 7-10 years my offices have been investigated by the OIG almost on a bi-monthly basis requesting our records for review. We have never been asked to give back any money or visited by an inspector because the documentation was thorough. We often treated our patients for months with no problems and got paid.


Many of you have bought my HIPAA manual online (go to and click on Forms and Templates). The OIG has a compliance plan that is very similar to the HIPAA manual Federally required. I have combined the 2 into 1 document. Should you ever have a visit by the OIG, show them the manual and if you have followed the guidelines I have outlined, then your office barring any blatant issues will have a positive outcome and you will get to keep your hard earned fees.


Should you not have my manual, then the formula is simple. Evaluate the patient every 30 days, keep good SOAP Notes and when the patient no longer exhibits positive findings upon evaluation, release them from active care.


You should have a system of checks and balances in your office to ensure that billing does not go out in error for these, or any other patients that exhibit no positive clinical findings. Every financial class has the same parameters, PI, WC and managed care. The rules are the same. Those systems of checks and balances are part of the OIG’s compliance plan to prevent fraudulent billing of Medicare.


By the way, the heading is a little misleading…The biggest threat to your practice is you! To remove that threat, document well!

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