Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 37
"Compliance Audits: What is Happening Around the Country"
Over the last 6 months, I have been reviewing charts and records of doctors nationwide, with an eye on how the insurance industry, Medicare and licensure agencies look at your records. The results indicate that 50% of all records would not pass the test to meet minimum standards of all documentation reviewed. This is problematic and reflects the current state of business of the insurers looking at doctors to make a “windfall profit” over the easy targets…chiropractors in the United States. This isn’t my opinion; it’s based upon the corporate culture of the insurer and their bottom line.
About 10 years ago, Allstate, State Farm, Geico, etc. changed their policy from the client first. Instead, they focused on the salaries of the CEO’s and other corporate officers and tied them into the profit of the respective companies. It was then that the policy of “Deny-Delay-Defend” was adopted, along with the doctor being an easy target, as a result of incomplete paperwork, laziness and indifference. In fact, the Federal Government ranks charge-backs with penalty and interest, similar to the IRS, and creates taxes that are one of the most lucrative areas for the Treasury. In fact, an article in the publication Family Practice Management said:
Ronald W. Bradshaw, MD, CPA
Given the federal government's increasing interest in ferreting out health care fraud and abuse, practices that don't implement compliance programs could be putting themselves at risk. While the development of a formal compliance program is outside the scope of this article, I do want to call your attention to one aspect of such a program that is relatively easy to implement, educational for you and your colleagues and potentially even remunerative: a self-audit of coding and documentation.
We have made self-audit work for our group of 14 family physicians and one nurse practitioner. It's easy and cheap, especially compared with the cost of external audits, which may be prohibitive for smaller groups (a small practice can expect to pay from $2,500 to more than $10,000 for an external audit, depending on its extent and the number of physicians involved). The only prerequisite for self-audits is having a good grasp of your coding and billing procedures before you implement the process.
If you are capable of performing a “self audit,” do so now and send a copy of the results to review for completeness. According to numerous health care lawyers, it is a very, very, very good idea (get the picture) to hire an independent auditing company to get an experienced outside “check-up.”
The results of 12 months in the Office of Inspector General, Medicare’s investigative arm reported for 2006-2007:
In FY 2007, MFCUs recovered more than $1.1 billion in court-ordered restitution, fines, civil settlements, and penalties. They also obtained 1,205 convictions. MFCUs reported a total of 607 instances in which civil actions were undertaken that resulted in successful outcomes. Of the 3,308 OIG exclusions from participation in the Medicare and Medicaid programs and other Federal health care programs in FY 2007, 805 exclusions were based on referrals made to OIG by the MFCUs.
The managed care and personal injury companies are in the same mode as the Federal Government in recouping money spent.
Allstate, Encompass and Nationwide File Largest No-fault Insurance Fraud Lawsuit in New York...
NEW YORK--(BUSINESS WIRE)--Dec. 3, 2003
$100 Million Dollar RICO Action Combats Insurance Fraud Scam
Involving 74 Defendants and Thousands of No-Fault Claims
The Allstate Insurance Company, Encompass Insurance and Nationwide Mutual Insurance
Company today filed a RICO (Racketeer Influenced and Corrupt Organizations Act) action in the Supreme Court of New York against 74 defendants, whom the insurers allege conspired in a vast insurance fraud network involving … and billing for medical services and diagnostics tests that were never rendered. The insurance carriers are seeking to recoup more than $100 million in compensatory and treble damages for thousands of no-fault claims paid as a result of the alleged fraudulent network of the defendants.
Many of these doctors are guilty of simply having incomplete records, as I have personal knowledge of this case and similar cases against chiropractors. There are more current cases, but the story is the same. My intent is not to scare you or make you feel uncomfortable because most, if not all, of you have no pressing or immediate issues. My goal is to make sure it stays that way for you.
It is my overwhelming suggestion to get a “check-up” in writing from a compliance company (this is a self-serving statement, as the compliance company is part of CMCS Management, as full disclosure is the best way to have a relationship). The current statistic is 50% of the files I review nationally, have documentation deficiencies. It is my goal for you to find them first, not have an adversarial who wants their money back do so. It is for this reason I have developed a compliance division, so the other compliance companies don’t take advantage of you for $2,500 to $20,000, which is the industry standard.
Remember one of the 3 biggest lies…your government loves you; they don't. Government is a business just like the insurance industry. In fact, the Office of Inspector General (Medicare’s Investigative Arm) is more aggressive than Allstate, State Farm and Geico combined.
A compliance specialist will look to see if your records reflect your billing and treatment, and match your evaluations, diagnosis and treatment plans. Actually, it goes much deeper. We have a copy of the insurance company’s checklist of what they are looking for, thereby making it easy to determine if you meet the criteria. Beyond that, your license has a standard as well that must be met.
Again…I SUGGEST IN THE STRONGEST TERMS TO GET A CHECK UP…
BEFORE ANYONE ELSE WANTS TO SEE YOUR PAPERWORK
A basic check up is included in this program. Make sure you send me all of your intake forms, along with a "blank template" of your initial evaluation and SOAP Note. If...you only have an EMR system, send me a completed inital record to review by faxing to: 661-843-1062