Gone Fishin’: Why You Might Be an Insurer’s Favorite Pond

A doctor called us using the kind of pressured speech and fevered pitch we recognize as the sound of someone in trouble. He’d received records requests from his local BlueCross BlueShield and the records he sent in didn’t pass muster. BCBS immediately upped the ante, asking for multiple records. Those were error-filled, too. By the time he called us, he’d been audited and 47 out of the 50 audited charts were either in error or incomplete. He’s now facing a deeper probe of 120 charts.

First: this crisis isn’t unique to BCBS, his state, or this particular doctor. Medicare and private insurers all over the country are sending out records reports at an unprecedented rate. Why? Because they’ve learned that up to 94% of all chiropractic documentation is in error, and a review will likely allow them to recoup a significant amount of money. We are, so to speak, their cash cows.

Second: when you start getting multiple records requests—and certainly by the time you’re facing an audit—you shouldn’t be trying to handle this on your own. Think about it: if you were personally audited by the IRS, you probably wouldn’t face them down by yourself. You’d want a tax professional by your side—either your tax attorney, or your CPA, or both.

In short: call us!

Why does it matter so much to have someone like us help you?

• You can’t know what you don’t know. Most common documentation errors aren’t due to typos or not bothering to do it right. If you don’t know what you’re doing wrong, don’t find out the hard way via an audit. Get on top of what’s required for clear, complete documentation before you’re in hot water.
• There’s actually a right way and a wrong way to respond to even simple records requests. You want to present the documentation in a certain order and accompany it with written clarification, so that what you’re sending in tells as clear a story of medical necessity and episodic care as possible. Remember, never completely edit or add to a record when you’re preparing for the request. If you must add something, a simple addendum is appropriate, but be prepared to explain why it was added after the fact if you’re questioned.
• Properly managed, a response to records requests can end the whole thing right there, long before things escalate into a full-blown audit. You want them to say, “You’re not the droids we’re looking for!”
• Learn whether this is a random fishing expedition or whether you’ve got a pattern of coding and documentation behavior that raises and waves red flags. Many insurers randomly reject as many as 25% of claims just because they know most chiropractors won’t appeal. Similarly, records requests can be equally random; with a 94% error rate, the odds are good a records request will show enough mistakes to justify further action. Or—and this is vital to know—you may be engaging in behavior that puts you at much higher risk: under- and over-coding, overreliance on a particular code, missing fields including—duh!—doctor signature, or documentation that doesn’t support medical necessity.

When we get called before there’s a problem, we can be proactive. We can review charts, much like a third-party auditor would, looking for documentation errors, coding blunders, and compliance concerns—and then we can deliver a written report of findings with suggested corrections before Medicare or a private insurer ever puts your documentation under a magnifying glass.

Doctors like our frazzled friend need, want, and deserve help, just as most of us would if we found ourselves summoned by the IRS. It’s vital to fill out Case Summary Templates correctly for resubmitting records, and in such a way that clarifies and justifies medical necessity and the codes chosen. Further, increased records requests are a sign that something’s consistently wrong in your documentation. An analysis of sample charts—or even a deep dive into the entire practice’s procedures, policies, and documentation practices—is a great way to get to the bottom of what’s gone awry.

When you don’t know what you don’t know, there’s very little to be done about it. The problem, for many doctors as well as people in general, is that we get weirdly comfortable and feel a false sense of safety by willingly keeping ourselves in the dark. It isn’t fun to find out things aren’t working well in your practice. But it definitely, most definitely, beats the alternative—which is having an auditor find out first.