Fraud or Lack of Medical Necessity?
by Bharon Hoag, CPC, CHC
Senior Consultant of ACOM Healthcare Consulting Group

Post payment audits of chiropractor charges by the Office of the Inspector General increased by 29% in 2006. Some providers have now paid back hundreds of thousands of dollars and still are not sure why.  This article will explore the situation and explain why it exists and what you can do about it.

In virtually all cases, the practices were found to have billed for services that were not medically necessary under Medicare/Medicaid policy. Were these charges truly not medically necessary?  At this point it does not matter because the doctors have been found guilty and have been penalized.  But going forward, every practice must adopt procedures to preclude or to deal with the possibility of such audits.

The right response
If you should get an audit letter, contact a coding and compliance expert before you admit to anything or agree to repay anything. The expert can help make sure you are protected and that you have an opportunity (1) to justify the claims in question and (2) very possibly overturn the ruling. Don’t be scared, be prepared!

What does it mean if they use the word “fraud?”  It is important to understand that to convict you of insurance fraud, they must prove that you deliberately set out in your billing to defraud the carrier. That is a hard standard to meet.  It is not difficult to prove that you did not intend to defraud anyone.

But does that mean that you are off-the-hook? It does not. You may not have committed fraud, but you still may have billed for services you were not supposed to be paid for. When you verify insurance benefits, you are only verifying policy coverage: it does not entitle you to anything and payment depends entirely on the patient and the true need for care.

So how do you convey that need? Through your documentation, narrative reports and SOAP notes. There is an old adage that says “If it is not written, it is not so.” This is a golden rule in healthcare. Ask any expert in the field of coding and compliance and they will tell you that if it was not written down, it is assumed that it did not happen.

Proper documentation
Next comes the question of what needs to be documented? That depends on what procedures you plan on performing with the patient. CPT coding has less to do with finances than it does with telling a story. For example, if you bill a 99203 -- new patient office visit, commonly known as a new patient exam in chiropractic - you are telling the insurance company you saw a patient that neither you nor anyone else in your group practice have seen in the last three years. You are also saying that at the minimum you took a detailed history, conducted a detailed exam and made medical decisions of low complexity.

Chiropractors get in trouble when they do not understand what they are saying in billing a procedure. Many make the mistake of merely looking at the financial compensation rather than the documentation requirements. How many of you actually KNOW what is required for a detailed history? If questioned, many doctors cannot come up with the right answer. If you are one of these doctors, you are not alone: it is endemic to the chiropractic profession. It is absolutely imperative to understand the codes that you bill and the story that they tell.

If your office undergoes a post-payment audit, the most likely place the medical necessity issue will surface is in the latter visits of the case. Our profession is inherently repetitive: notes begin to reflect sameness, visit-to-visit. Compounding the problem is the fact that there are new technologies available for chiropractic offices that are marketing the ability to hit a single button to reproduce your note for that day from one written previously. Well, isn’t the patient the same as he/she was on Monday? The answer is no, but you have to demonstrate that fact with documentation based on your findings and reflecting each situation as it currently exists.

Know the definitions
Sometimes changes are subtle: seek them out and document them.  Don’t take short-cuts. Show the functional changes in your patient on a visit-to-visit basis. Take pains to understand how carriers define medical necessity.  Here are some examples of actual Medicare definitions:

• Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, arrest or retardation of the patient’s condition.
• Chronic subluxation: A patient’s condition is considered chronic when it is not expected to be completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered.
• Maintenance Therapy: A treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life; or it is therapy that is performed to maintain or prevent deterioration of a chronic condition. These are not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.

Show results
Based on these definitions, you can see that you must document some sort of functional improvement. How can you do that when you are only saying that the patient pain threshold is a two out of ten … and when it says the same thing on five of the last six notes?

Again, document how you think. Ask the right question! Don’t ask your patients how they’re doing; you will get a canned answer. Ask them how they’re functioning … how is it getting in and out of bed … in and out of the car, and so on.

Ask functional questions and you will get functional answers. This will keep your subjective more alive and vital. It is not hard to produce good documentation. You just need to know the rules and the definitions of the terms. If you fear an audit, it is likely because you are not prepared for one.

Get prepared! Call us and we will show you how. Control your future.

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