In Part One of this post (5 Chiropractic Audit Errors You Need to Fight), we discussed the fact that audit errors are common and that they absolutely need to be appealed or fought.
Specifically, we mentioned three that you would need to get your boxing gloves on for:
- Statistical Extrapolation
- Failure to Adhere to Appeal Guidelines
- Improperly Offsetting Checks
In this segment, we will cover two additional chiropractic audit errors for which you must get out your sword and defend your hard earned money. Let’s dive right in!
4. Consulting Auditors Vs Clinical Review: over the last few years, we have all come to understand that auditing is big business. But if you examine your provider contract or even listen to the payer’s rationale for auditing, the intent of examining claims is not to create a business income stream for payers or federal entities (although it certainly does!). The intent is to ensure that claims are paid properly, to reduce fraud, abuse and waste. As such, the focus of the audits are designed to be on clinical review of the services performed, not on a consulting model whereby a for-profit company identifies opportunities to increase income through recoupments.
You can dive deep into payer policies, examine Medicare’s many mounds of paperwork in their fight against fraud to validate this and at the core of auditing, there lies a clinical review of what you’ve done. Furthermore, there are state laws, provider contracts and even accepted principles of auditing that dictate how an audit is conduct and, importantly, WHO conducts the audit.
For example, a nurse reviewing claims by a chiropractor who makes a determination that the treatment was not medically necessarily could (and should) be deemed inappropriate. Why? For starters, she is not a chiropractor and therefore should not be reviewing claims outside her specialty or expertise. Put the shoe on the other foot and ask yourself how qualified you would be to review the medical necessity of a surgical procedure on the prostate? Hopefully, you would agree that you are not going there.
All too commonly, however, insurance companies ignore basic principles of auditing as set forth by the Utilization Review Accreditation Commission (URAC) – despite the fact that payer boasts of membership and accreditation help by URAC. In case you are unfamiliar, URAC is the entity that creates standards for auditing by which its members (insurance companies and even auditing firms) are supposed to adhere. Put simply, “proper” auditing occurs when an independent entity (URAC) uses trained reviewers to examine an organization’s operations and to ensure that they are delivering health care in a manner consistent with national standards.
What does this mean for you? Many (or most) reviews performed by auditors who do not possess the same degree, who only practice in their nightmares and/or who don’t even hold an active license — any or all of these very common occurrences – would FAIL to meet URAC standards. Worse yet, most of these payers have pledged to conduct their auditing according to these standards. For a list of payers who claim to hold URAC standards, you can check out their website via one of the links here.
The good news, however, is that this gives you an opportunity to fight how the audit was conducted. Of course, few chiropractors know or understand this, and therefore don’t know the leverage they possess in “calling foul” with these accredited standards. But now you do and now you understand why this issue is one to fight!
5. Statutes of Limitations to Recoupment: One of the most powerful ways to fight an audit and, unfortunately, one of the most commonly abused areas of auditing is in the arena of limiting how far back the payers can legally go back to take your money out of your pockets. Each state has its own statute of limitations that dictates the legal limit for recoupments. But apparently, not all payers have interest in being a law-abiding entity. In nearly half the cases we review, the payer steps over the line of legality and asks for money back that they cannot rightfully have.
For example, we recently helped a doc where the statute of limitations in his state was 24 months but the payer attempted to go back a full 36 months and get his money. Since this was an obvious violation of state law, we were immediately able to reduce the scope of the audit and its potential damage.
Of course, this is another area where payers expect you to be ignorant and so they will routinely attempt to go back further than the law allows. Don’t let them do it.
To help you prevent audit demands from getting out of sync with their proper timeline, we have created a chart of Recoupment Laws By State (click link to download) which details the legal limits and references the statute of limitations. Obviously, it’s too bulky to include in this post, but you can download it for FREE and for fighting (if needed). Just click the link above to get yourself a copy!
NEXT STEPS
I hope this two part series has been helpful for you in learning some more about what types of chiropractic audit errors you should appeal and how.
Don’t forget to keep your FREE Recoupment Laws Chart handy to make sure that the payers don’t try to slip in some “extra” auditing beyond what they are legally allowed to do in your state. You deserve to keep your hard earned money and the law is on your side for helping you do just that!
