Audit Defense Strategies Jeremy Haug March 2, 2022
Audit Defense Strategies

Best Defense Against an Audit?  Do it Yourself. 

The Chiropractic business model was much simpler 40 years ago.  Perform a service, bill for it, and get paid.  Unfortunately this allowed for a few bad eggs to abuse the system and collect payment when they shouldn’t have.  In addition insurance companies are keen to spend as little money as they can in order to stay profitable.  After all, they have a duty to their shareholders to improve their own bottom line.  With the current trend by payers to perform post-payment audits and refund demands, it’s no longer about if an audit is coming, but when.  Audits are a very effective way for payers to reduce their expenses, especially if they can find doctors who are careless and sloppy.  The best defense is a good offense.  Odds are good that every office will be audited sooner or later, so why not beat them to the punch?  Perform a self-audit.  It is technically required as part of a mandatory Compliance Plan anyway (thanks Obamacare!).  An office that is vigilant about its own records, coding, and billing will be able to rest easy when asked to send in records for a post-payment review.   

Get inside their heads 

It can be helpful to know how auditors work and what they look for.  Many auditors are paid on a commission basis (typically 9-14%), therefore they are motivated to find mistakes.  They often use statistical sampling software as a starting point to identify potential offenders.  This software can follow a 16-20 point criteria and require a minimum of 80% to “pass”.  That means that a clinic can only miss on 2 or 3 points.  If a practice audits itself, it can identify weaknesses and address them before a third party demands a refund. 

Auditors know which mistakes are made most commonly by Chiropractic Physicians.  They will go after the easy things first.  Most of the time, the doctors involved are not deliberately deceiving others, rather they have not taken the time to understand the proper guidelines.  Chiropractors are notorious for lack of support for medical necessity, generally due to poor documentation.  Proper documentation will ensure that an external auditor never has to ask the provider any questions.   

Look for these problem areas when performing an internal audit.  

  • Without a care plan it is very difficult to establish medical necessity.  It just looks like care goes on and on for no reason.  An effective chart note will include a clear plan that outlines goals and measures progress towards those goals along the way.  Outcome assessment tools are a valuable part of this process and it goes without saying that these plans need to be individualized and updated every thirty days. 

  • Diagnosis and procedure mismatch- Many office software programs fill in a default list of diagnosis codes.  Auditors know that everyone is not the same, so not everyone will have identical diagnoses.  Make sure the documentation supports what is listed on the claim form.  Don’t use unspecified codes unless you have to.  If every procedure code points to every diagnosis code, it may imply that the biller and/or doctor does not understand how to use the codes properly.  Match specific procedures to specific diagnoses.  

  • Improper use of modifiers- Because of the National Correct Coding Initiative (NCCI) we know that certain codes are only reimbursed when the -59 is attached.  Too many billers add the modifier because they were told that it is the only way to get paid.  While that may be true, the modifier really tells the payer that the service was performed in a different area or on a different visit than the other billed code(s) that day.  If this is not documented, then the modifier is being abused.  In fact, this is why one large insurer now requires documentation before they will consider payment for 97140-59.  After auditing the DCs in their network, they determined that 90% of them used the modifier improperly.   

  • Routine billing- Medicare keeps statistical data on the distribution of 98940 versus 98941 versus 98942 billed by physicians.  In fact, many doctors have received Comparative Billing Reports which let them know how they stack up against other providers in their region.  If 90% of the claims in a given clinic include a 98941, that clinic will fall outside the bell curve and be an easy target for auditors.  This is not to say that every doctor must have the same averages, rather they must be prepared to justify medical necessity for anything outside the norm.  The latest numbers are approximately 32% 98940, 61% 98941, and 7% 98942. 

  • Upcoding One doctor was sent to the fraud unit of a private payer for billing 99204 on every new patient.  While some patients may need an exam that is this thorough, it would not be routine.  Get familiar with Evaluation and Management (E/M) audit guidelines (three key components, time override).  Some tools are available free online.  It can be complex and may take an hour or two to learn, but once understood it is a valuable skill that will help on many claims.  (Except that providers change the rules every once in a while).  The underlying guideline is that the provider should select the code that accurately reflects the service provided.  Seek out additional training or resources if necessary. 

These are just a few of the issues that auditors look for.  Keep in mind that everyone will likely be audited sooner or later.  When that happens, an effective self-audit can minimize surprisesAnd remember that insurance companies have teams of experts at their disposal.  It may be wise to enlist your own team of experts.   


Dr. Gwilliam graduated as valedictorian from Palmer College of Chiropractic in 2003 and later earned a Master’s of Business Administration.  He is also a Certified Professional Coder, Medical Compliance Specialist, and Certified Professional Medical Auditor.  He speaks on compliance and coding topics all over the country as Vice President of the ChiroCode Institute.  He can be reached at