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Eliminating the Auditor’s “Ace in the Hole” to Protect Your Chiropractic Practice

In poker, the term “ace in hole” refers to a move that is sure to earn a win in the card game. Unfortunately, many auditors are walking around with their own “ace in the hole” and prepared to pull it out of their sleeve to demand repayment from unsuspecting chiropractors.

Fortunately, if you read today’s post carefully, you will learn how to eliminate this small, but potentially deadly audit mistake. Truthfully, most chiropractic billing experts would agree it’s a bit sneaky. But it is technically “by the books” so you can’t fault payers like Medicare or other commercial payers for going to their auditing “ace in the hole” when necessary.

When I first read of payers using this audit trap, I admit that I thought that it was a blatant scare tactic to make providers unduly nervous or perhaps somehow reinforce the push to get everyone on electronic health records. Unfortunately, Medicare has released multiple warnings in the past several years reminding physicians about this issue and other payers are using the same strategy to ensure that you are hard pressed to defend the right to each and every penny they demand back in a post-payment audit.

In fact, I’ve seen this tactic used by four different payers just in the last several months of helping chiropractors with audits.

The Achille’s Heel of Your Audit

Let’s face it: the prospect of an audit doesn’t hit anyone gently.  But if you have billed things properly, used correct chiropractic CPT codes and documented your services accurately, you should stand a good chance that you don’t have to mortgage your house or sell your first born to pay the payer the gargantuan sum that they have slapped you with.

That is, unless they aim the audit squarely at what appears to be the “achille’s heel” of chiropractic documentation.

What’s our weak link?  The miniscule missing item that drags us down amidst much kicking and screaming?

It’s your signature.

Yes, that’s right.

Despite all your sweaty fears, your documentation actually passed the test.  Your billing- spot on.  Coding was correct.

I’s dotted and t’s crossed and just when you think you’ve cheated death and avoided the sting of the auditors accusations, the payer comes back and lays down his “ace in the hole” with a deafening, definitive thud.

Signature Requirements

Chiropractic Signature Requirements for Medicare

“Medicare requires that services provided/ordered be authenticated by the author. The signature for each entry must be legible and should include the practitioner’s first and last name.”

Before you get too optimistic and think that this is just Medicare’s oddball rule that can be randomly enforced, check out the remarkably similar signature requirements for other payers:

BCBS of Kansas Chiropractic Signature Requirements

All notes should be signed and dated by the clinician performing the services. A legible first initial and last name is minimally required. If not present, reimbursement will be denied. A stamped signature is not acceptable. 

BCBS of Massachusetts Chiropractic Documentation Guidelines

The record shall be kept in chronological order and record entries shall be made contemporaneously. Each such entry shall be signed by, or shall otherwise adequately identify, the registered chiropractor who is treating the patient to whom the record pertains.

A quick review of your local commercial carrier’s documentation requirements will likely reveal similar language.  The bottom line? Sign your note or else!

Alternative Signature Solutions 

If this article has you antsy, there are a few solutions you can employ to legitimately provide a signature.  Unfortunately, the “alternative” options are not quite fool proof, nor are they the preferred method because they have to be utilized in a compliant manner and cannot simply replace your forgetfulness.

Option 1 – Sign Your Note

  • The simple and obvious solution: get with the program and sign your note.  Read Medicare’s Signature Guidelines (starts at page 36) to see acceptable versions of your signature.

Option 2 – The Signature Log

  • If you’re still a paper pusher and still holding out on moving towards EMR (another issue for another day), the idea of signing your note may be a bit tough to swallow, creating a signature log may work
  • A signature log essentially allows you to sign your note, but then have a separate form that identifies your signature throughout the records.  This is good for those who know their handwriting is going to produce illegible chicken scratch and therefore run the risk of going through the trouble of signing the note, but not having their signature count because no one can read it.  The good news is you can create a signature log at any time.  The bad news is that your signature still has to be present in the record in order to create the log.

Option 3 – The Attestation Statement

  • If a payer creates an issue with your signature (illegible, can’t verify whose initials are whose, etc) then you can complete an attestation statement to verify that those signatures are in fact your 100% original work of art.
  • Here’s an example of a Medicare Attestation Statement (you can google one for your carrrier, but they are all basically the same)

Chiropractic Signatures and Timely Documentation

As demonstrated above, what won’t cut it with payers is a lack of any signature in your daily notes.

And most payers make it abundantly clear that you must sign your notes in a timely manner. Altering the records after the fact is not acceptable.  In fact, it may be even considered fraud. (See my post on How to Amend Your Chiropractic Documentation and How Not To)

You may ask — what exactly is timely documentation?  Frankly many payers have differing definitions of what constitutes a “timely” record.  On the short side, some payers will define this as the note is completed within 24 hours.  Others it’s longer, such as 72 hours.

In December 2016, CGS Medicare weighed in on the debate on requiring a “two day” requirement for medical records and came out with a mixed conclusion that “10 working days should be ample time to finalize a visit note and sign/authenticate it.”  But they even conceded that “an attestation be used for documentation containing, late, missing, or illegible signatures.”

So while the date may be murky, the message is clear: your documentation must be done promptly (not weeks or months later) and signatures are required.

What to Do NOW!

Take this to heart – sign your notes.

This is the quickest and simplest route to improving your chiropractic compliance.

Will that fix everything and make you compliant?  Probably not.  As we’ve mentioned previously, chiropractors are subject to HIPAA deadlines, fee compliance, billing, coding and documentation compliance – all of which obviously include much more than signing your note.  We teach those in our seminars, that’s what our coaching clients hire us to help and there’s an abundance of free articles here on our blog.  Though I’m not sure where you need to start, the first step to overcoming your challenges is to assess where they are. And if the signature is all you have to fix, then congratulations — but fix it fast!

And if you have experienced a chiropractic audit, don’t get out your checkbook to pay the payer back, get help.  There’s many ways to fight post-payment demands (beyond just paying back the payer.)

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