Chiropractic Coding & Compliance Alert

Use these strategies to wade through tough payer scrutiny

If you’ve noticed an increase in the number of payers auditing chiropractic services in the last few years, you’re not alone. Most recently, Noridian Medicare stated on June10 that it will be shortly initiating a widespread probe on claims using CPT® code 98941(Chiropractic manipulative treatment [CMT]; spinal, 3-4 regions), which happens to be exclusively used by chiropractors. Read on to be forewarned of the caveats regardless of who your payer is. 

Background: Noridian is the Medicare carrier for the Northern states such as Alaska, Arizona, Washington, Montana, North Dakota, South Dakota, Oregon, Idaho, Wyoming, and Utah. Given the high error rates of chiropractic claims in the past, Noridian will also be conducting a CERT auditing as a required protocol of the Medicare program.

What to expect: If you fall in the Noridian jurisdiction, you might well be the recipient of the random CERT audit that Noridian will be conducting on chiropractor claims for code 98941. In case this happens, they will send in a notice for you to submit your documentation, for which you shall have 45 days to comply. 

“I feel they are targeting the 98941 because they don’t understand how chiropractic helps the elderly population,” opines Doreen Boivin, CPC, CCA, with Chiro Practice, Inc., in Saco, Maine. She further explains, “In chiropractic, treating the whole person helps the patient heal faster and better. When a chiropractor is limited to one region at a time it seems to take longer and create issues in other areas of the body. It’s like the domino effect, when one falls they all fall. Well, with the spine it doesn’t make sense to adjust only one region because then you have only started the healing for the one region and paused it for the rest of the body.”

If you receive notice of an audit, you probably will find yourself asking some of the same questions as many other practices. 

• Should the payers be legally asking for refunds? Legally speaking, yes. If a payer is reimbursing either the provider or the patient, they do in all fairness have the right to ask questions about the claims.

• What’s the best way to survive the audit? It’s a battle of nerves and confidence. Auditors exist to find gaps and show that our documentation has to improve. They may even make you feel having grown wiser through a small payback of say, $400. Some providers might just pay the amount and get on with life, never thinking about whether they’re eligible to appeal. Don’t let that happen to you or your hard-working practice.

• Can we write off the money? Think again: Everyone knows that for a medical practitioner, patient care would always be a priority over other things. Some DCs might just write off that $300 shortage and get on with the next patient. You think that filing an appeal for this amount isn’t worth the time and effort for you? Just think of the whopping amount the payers are set to gain collectively from say 3,000 such preoccupied Noridian DCs.

Look for 5 Ways to Conquer Audit Challenges

It’s time now to get ready to work your plan with the following strategies:

1) Re-read the audit points in minute detail: Remember that auditors themselves receive a contingency fee proportionate to the recovered amount, which some feel could be an incentive for them to target high dollar claims. That said, all humans may make inadvertent mistakes, which means your first defense should be to double check the audit points and see if they truly apply. 

• If you find that your documentation is fine and that all the facts are in place, you can appeal straightaway. 

• If you find the queries really point out deficits, you can take this as an opportunity to make sure they won’t happen again.

• Doing this audit review is sure to bring down your error rate, and thereby the payback amount.

“Read, read, read and make sure you understand,” says Boivin. “If you don’t, make a phone call for clarification. It’s important to supply what is being asked for.”

2) Don’t give up – appeal: Do not lose hope. In fact, whenever you face such a situation, your first move should be to appeal. According to the Medicare appeals data available online, more than 60 percent of the appeals won, and the post-payment demands were overturned.

3) Get an attorney: You need to decide on this according to your analysis of the situation. Weigh the benefits and choose wisely. One simple parameter would be comparing the fees with the payback amount at stake. Another important thing to consider is that the attorney you seek should have a good background of handling chiropractic post-payment audits.

4) Negotiate for best results: All is not lost if you do have to repay an insurer. Try your hand at negotiation, in all humility. Do a little homework to convince them that the extrapolated error rate may not rightly reflect the actual deficit and that they may consider this in your favor.

5) Evolve with your documentation: It’s worth it to invest some time to develop a system of good documentation. This is an absolute remedy that will let you withstand any scrutiny. “I can’t stress enough – DOCUMENTATION, DOCUMENTATION, DOCUMENTATION! Follow the P.A.R.T for each visit and you can’t go wrong,” advises Earhart.

 (You can refer to “8 Easy Ways to Keep Your Claims on Track” in Chiropractic Coding & Compliance Alert, Vol. 1, Number 1, for documentation basics).

Arm yourself: Follow the ACA documentation guidelines. Take the time now to get it right so in the future you don’t have to fight for getting paid. Knowing how these measures fit with your practice can benefit you now as you focus on delivering quality care, and help you prepare for additional compliance focuses in the future.

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