Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 28
Over the last 3 weeks, I have gotten calls from doctors all over the nation that are either being sued, called in for an EUO (examination under oath) or visited by SIU (special investigative units) from insurance companies. The tactic “du jour” is to attempt to get the doctor to re-pay the insurance company the fees paid to the patient for services previously rendered, and often for seemingly “petty” reasons. Furthermore, if you are under investigation for fraudulent issues, the insurance companies do not have to pay your current claims under state and federal laws. This allows the carriers to “float” your money and increase their profits.
The problems with this tactic for the doctor are first, you do not get paid for valid services rendered and you are required to hire a health care lawyer, often for $400 per hour, to defend yourself. At the end of the day, your legal bills can go well into the 6 digit range, with a disruption of cash flow. It is not a happy place to be.
What do you need to do to “bulletproof” your practice? There are many critical areas that will allow you to satisfy the reimburser’s need for verification that your claim is “clean” from their perspective. This issue is not limited to PI patients, as many managed care carriers have been “going after” doctors with equal fervor. In fact, Medicare has often touted doctors repayments as a prime source of income for the Federal Government.
When you send in a claim, attach a copy of the notes, evaluation or test results that correspond to the services billed on the claim. The primary reason for being investigated is patterns of practice. Each doctor is profiled on diagnosis, number of visits and number of specialist referrals. In this computer age, it is easy for carriers to track your practice patterns.
What carriers look for is a clinical rationale for services rendered or ordered. If you include a copy of your notes, there is no longer that question as to what was done and why. The answer will be in front of them, therefore removing the necessity to ask the question.
Does this mean you should limit your referrals? Absolutely not! It does mean you have to document more thoroughly, as all evils in a doctor’s office begin or end with the quality and completeness of your documentation.
You must do a complete evaluation with history, past history, examination, and tests ordered, with the clinical rationale of why you ordered those tests. First, your reports must be legible; if no one can read them, they are useless. If you utilize a computer generated report, each encounter must be customized. If you hold 10 reports up and they are all alike, it is as bad as not being done and you will rightly be accused of running a “mill.” When doctors testify as expert, many are accused of using a “canned report” to discredit the results. It is a tactic successfully argued if the report appears to be a template document and often will be upheld to dismiss your work. The carriers look at those types of reports similarly if not customized.
Evaluation report verification issues:
- X-rays taken were ordered in your evaluation report
- You need to have written orders for x-rays, even if you take your own
- Treatment frequency ordered does not match frequency of services rendered
- If there is an exacerbation and frequency increases, then a re-evaluation must be performed to document the change of frequency
- No diagnosis for areas treated (diagnosed C-Spine and adjusted C-T-L spine)
- No diagnosis for x-rays (C-Spine diagnosed, L-spine x-rays taken)
- Re-evaluations not ordered
- Re-evaluation not performed every 30-45 days, as prescribed by Federal standards (every state follows Federal standards)
- Clinical rationale for all ordered tests and DME’s (durable medical equipment)
For verification purposes, I urge you in the strongest terms to include your clinical rationale for tests ordered. As an example, “The cervical MRI was ordered to rule out a space occupying lesion, as Mrs. Jones has pain radiating down her arm with a positive foraminal compression test.” This removes the issue of overutilization, as you are explaining why, and it leaves no questions to be answered.
A complete SOAP note MUST be completed for every visit. This is non-negotiable. Travel cards are a thing of the past and are a liability, as most travel cards are limited in being able to document thoroughly.
Your SOAP note should have an accurate entry for every category (SOAP) each visit. The SOAP note should reflect the continuum of care of your patient and how your patient is progressing through your treatment. A SOAP note is not an evaluation.
Many doctors use the SOAP note format for their evaluations and this is problematic and very difficult to justify when billing for a 99213-4-5, as the elements needed in those CPT’s are not satisfied. Therefore, it exposes you to billing fraudulently for services not performed.
If there is a change in condition, or a patient tells you they are having a problem as a result of their injury or condition, it should be noted in the SOAP. Should you have to change the treatment plan for any reason, this is not done in a SOAP format. A full re-evaluation needs to be done. It can be a low level 99212 or an intermediate level 99213, depending upon the clinical presentation, but you cannot change your treatment plan utilizing a SOAP note format.
- Treat areas not diagnosed
- X-Ray areas not diagnosed
- Go beyond 20-45 days without a re-evaluation with ongoing care
- Order durable medical equipment without an order and clinical rationale
- Order tests without your clinical rationale documented
- Send in claims without your reports to support your treatment plan
- Alter from your treatment plan without amended orders
- Take x-rays without orders in your evaluation as part of your treatment plan
- Treat without positive clinical findings
- Give the same treatment plan to every patient
- Order the same tests for every patient
These few areas are the most problematic areas that trigger an inquiry or law suit. Beyond the legal issues, these practices should be adopted from the beginning of practice, as it is consistent with standards of our professional training.