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For several years now, the chiropractic profession has been the focus of the OIG Work Plan, and that meant audits and recoupments. You’ve heard this before, nothing new. Those Medicare audits ranged from just a few charts to an unsettling 40 charts to a horrifying 100 charts with practices looking to companies like KMC University to teach them how to prepare, fix what is wrong, and survive.

Until now, this was almost exclusively a Medicare-related occurrence. But with private insurers falling in line behind the government, it has become increasingly common for records requests and audits to come flying in from all directions. Because of this focus, DCs and CAs must learn more about rules and regulations, adding “documentation experts” to their many hats.

What’s Behind All This Random Auditing?

If you had the time to look this up, which none of us do now that all of these regulations are in place, you’d discover that one of the key provisions of the Affordable Care Act was to move the Medicare fee-for-service system into a pay-for-performance model. The primary resource for this shift – quality measurement. If you look at the regulations, you’ll find an entire manual devoted to Quality Improvement Organizations (QIOs), groups that can be formed to help Medicare carriers meet these quality standards. None of this is new to us, but there’s a significant issue you might not have expected. Marketplace plans (the subsidized plans that give tax credits or have low premiums for lower income families) are also using the QIOs to help them credential and qualify to sell plans on the Marketplace and be responsive to CMS.

The Center for Consumer Information and Insurance Oversight was formed as part of the Affordable Care Act. The purpose of this organization was to ensure that plans provided through the Marketplace have consistent quality. You may have already received one of these requests from one of your other carriers. It may have a short response time to provide documentation for just one or two patients during a specific time-period.  Some of these carriers offer Medicare Advantage plans, and some do not. It seems random until you consider that the Center for Medicare/Medicaid Services (CMS) requires carriers who offer Marketplace plans to document quality by using quality audits just the same as Advantage plan carriers. The letters you receive seem very bland with no threats of recoupments or discharging you from participating. However, should you fail this audit, be certain that the report will go to the carrier, who will follow with increased auditing and improvement plans.

What Should We Do Now?

Keep good records of the audit requests you receive and the timelines you’re given. Responding on a timely basis is an automatic check in the positive column for you. Learn how to review your office documentation. As part of a complete compliance plan, your office should self-audit regularly. Doctors can get overburdened and let these requests lag—not a good idea. If you get the training to pre-screen your office documentation, you can save a tremendous amount of time. Make a task list for your office regarding this issue. Keep records detailing from which carriers and QIOs you’ve received requests.

Lastly, keep your cool. Documenting for medical necessity is essential in a reimbursement model world. If your office is submitting claims, documentation is the driver, the doctor is the engine, and the CA is the oil that keeps all the cogs moving smoothly. Get training in anatomy and terminology and in documentation review to help your office.  It has never been more important.

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By Kathy Weidner

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