What Not To Do When Faced With an Audit Mary Martin September 24, 2013
What Not To Do When Faced With an Audit
Blog best EHR software chiropractic What Not To Do When Faced With an Audit

David Klein, CPC, CHC

Chiropractors are well aware of the large increase in post-payment reviews and audits, as well as the heightened emphasis on correct coding and proper documentation. This growing scrutiny has led many providers to feel that insurance companies are out to get them. This feeling often translates into fear and an adversarial approach when dealing with insurance carriers. Be advised: this approach is counter-productive!

I used to be the billing and compliance manager for a group of 35 chiropractors. We were faced with an audit, and I took it personally. “Don’t these insurance companies know we are trying to do our best for our patients”, I wondered? I was angry and concerned. In my first conversation with the investigator, I told him the only reason he was reviewing these claims was to make money and justify his existence. My approach did not have the desired effect. He became defensive and quoted certain stipulations in our provider agreement that empowered him to subpoena our records if we wanted to go that route. Immediately, my anger turned to regret. Why was I trying to provoke the investigator?

I recently had a conversation with a senior investigator at one of the nation’s largest private health insurance companies. He was very forthcoming, shared his perspective, and dispelled the myth that all carriers are out to get the doctor. Here is what he said:

  • Keeping good relationships with providers is good business for insurance carriers who rely on happy clients to renew their contracts every year.
  • Insurance companies appreciate well-educated providers. They want providers to know the rules and do things according to the guidelines.
  • Most coding errors involve a misunderstanding of the rules — only 10-15% of cases reviewed involve fraud.
  • If faced with an audit, send in your records as soon as possible because long, unjustified delays can cause questions about the validity of documentation.
  • Wait to hear what carriers conclude before questioning their intent or the validity of the audit.

It’s true that audits and post payment reviews can be scary, time consuming and costly. And, it’s natural to feel overwhelmed. However, if you take a proactive approach, you will be much more likely to handle these situations gracefully, successfully and confidently. So remember:

  1. Educate yourself – find qualified experience sources for information.
  2. Know the coding rules – improper use of codes and modifiers can make you an easy target.
  3. Learn proper methods of documentation – it is the key to justifying and supporting care.
  4. Employ systems and software in your practice that drive outstanding compliance.
  5. Establish good, positive relationships with carriers – it is in your best interest.

Of course, there may come a time when you need to fight for your rights. In the meantime, becoming better educated and developing positive relationships with your insurance carriers can protect you and your practice and reduce the likelihood of negative and costly reviews.