Basic 2 Insurance Audit Know your state laws

Basic 2 Insurance Audit Know your state laws

What to Do When Your Chiropractic Office Receives an Insurance Audit. Unfortunately, for many chiropractors, it’s no longer IF you receive an audit letter from a third-party insurance payer (like Medicare, Blue Cross, Aetna, etc.) but WHEN you receive one! Despite the fear and anxiety that receiving an audit notice can cause, going into full panic won’t help. Instead, here are some tips for managing your chiropractic audit effectively, efficiently, and successfully:

1. Extreme behavior is not necessary!

While receiving an audit letter can certainly bring out extreme emotions, responding to extremes won’t help. In other words, don’t panic and ignore the letter. Just because you received a notice of a planned audit—whether from Medicare or any other third-party payer—doesn’t mean you’re guilty of an offense. Some audits are completely random and performed routinely without any suspicion of your billing activities, documentation capacity, or processing parameters. So don’t panic in the presence of an audit letter. Don’t assume your documentation is substandard. Don’t automatically determine that they will find your records insufficient and make plans to be subversive. On the other hand, do not ignore the audit letter. Instead, plan to take action.

2. Know your state laws! Insurance Audit

You have legal rights depending on the state in which you practice regarding how audits may be conducted in your state. For example, if you are an out-of-network provider, the carrier may not be able to audit unless they suspect fraud. On the other hand, a government entity like Medicare can certainly audit you, so take the next step. Perform your due diligence immediately and find this issue.

3. Choose your battles. Insurance Audit

Once you have determined that the audit is legitimate, you need to determine exactly what is being audited. Do they ask for a records check where they want to see your medical records? Would they like to make a site visit? Once you have determined the type of audit they intend to perform on your practice, you must formulate a response to that audit in a timely manner.

In some types of audits, no response is the worst possible response you can give. You, therefore, want to respond to the audit request as soon as possible. Also, provide what is requested: nothing more, nothing less. Auditors don’t want to review a 42-page explanation of your table notes; they should defend themselves. Additionally, any additional material you provide beyond what is requested may also be used against you. A word of advice: do not respond to audit requests by telephone or fax. Get it in writing!

4. Bad is better than fake. Insurance Audit

Once a chiropractor receives an audit notice, the most common question I get asked is, “What should I do to prepare for this audit?” To be frank: the time to prepare for your audit is not when an audit request letter is in your hands! Never take matters into your own hands and edit medical records to improve what appears to be incomplete or insufficient documentation. Poorly made records are always better than the best records that have been fraudulently invented. Better to have bad grades than false grades.

5. Be on time! Insurance Audit

If you have to respond in 30 days, then respond in 30 days! If the delay requested by the carrier is not reasonable due to extenuating circumstances, contact the verifier for an extension. If it takes you longer to produce the information, ask for an extension.

6. Should you appeal? Insurance Audit

Frankly, not all insurance reviews are accurate. Therefore, to protect your interests, recourse is sometimes necessary. Particularly if you have high-value claims in question, you want to consider appealing. If your “verification” letter is actually a refund request, your best option may be to initiate the appeal process. Do not automatically assume that the payer’s review is final or even correct. If so, one call can save you thousands of dollars in unnecessary refunds and headaches.

7. Do you need help? Insurance Audit

You may need to get help from a Certified Professional Coder or a Certified Professional Medical Auditor whose expertise is in chiropractic to help you defend yourself. A health care attorney may also be advised, especially if there are multiple zeros in your request or reimbursement letter. Again, before you press the panic button or pull out your checkbook, getting professional help can be critical to the success of your defense or appeal. The reality is that your license, your lifestyle, and your livelihood may depend on it!

My first hope is that you don’t get an audit letter. But if and when you do, keep this list in mind so you can successfully defend your claims! Insurance Audit.


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