The first quarter of each year often sees a wave of new rules, requirements, payer policy changes and, unfortunately, audits.
It’s essential that your office keep up with these changes that happen both on the national and local level (which is one big reason why you want to catch one of our chiropractic billing, coding & insurance seminars at the start of the year, so you can be aware from the beginning.)
This year is no different – but in the wake of all the new stuff that is coming our way, I’d like to point out two “audits” that should NOT alarm you (and one you should definitely pay close attention to).
HEDIS Reviews are a tool used by more than 90% of health insurance plans to measure performance on a variety of different aspects of care. The name HEDIS stands for Healthcare Effectiveness Data and Information Set (HEDIS) and the tools consists of 71 measures across 8 “domains” of care.
Because so many plans collect HEDIS data, it’s likely the HEDIS review request will cross your chiropractic desk, but don’t be alarmed by the term as it’s nothing to worry about and, in many cases, may not even be relevant to your practice.
HEDIS is just an attempt to compare the performance of health plans on an “apples-to-apples” basis. HEDIS measures address a broad range of health issues, among them are the following:
- Asthma Medication Use
- Persistence of Beta-Blocker Treatment after a Heart Attack
- Controlling High Blood Pressure
- Comprehensive Diabetes Care
- Breast Cancer Screening
- Antidepressant Medication Management
- Childhood and Adolescent Immunization Status
- Childhood and Adult Weight/BMI Assessment
As you can see, this is just a reporting tool and nothing much to worry about, so let’s move on to the second equally harmless “audit.”
The next “audit” is really just a review and update of your provider information that payers are required to monitor on Medicare’s behalf. In fact, the penalty portion of the directory review is really aimed at the payer – not you.
So when you receive a request to “validate” or “review” or “audit” your directory information – rest easy. The payer in question is just attempting to keep your information accurate. The simple thing to do is to respond to this request, as accurate information helps you as well.
The Directory Audit is fairly straightforward. Your office is contacted and asked about your participation with certain plans. This information is fact-checked to Medicare’s database for those plans and that’s it on your end.
For the payer, they are required to report accurately to Medicare and if it’s determined that a significant portion of their panels has inaccurate information, they can be fined up to $25,000 by CMS. But again, there’s no penalty on your part so this is another “audit” to breathe easy through.
Chiropractic Medicare Audits
The final set of audits we’ve spoken about previously but it’s worth mentioning again. These are audits coming your way via your local Medicare carriers.
Unfortunately, these audits REQUIRE response (which also happens to be the #1 error chiropractors make). Failing to respond results in an overpayment determination (translation = you get to pay Medicare their money back) AND will likely result in future audits as well.
So be prepared. Due to the poor performance of chiropractic providers last year (and previous years prior to that), it’s likely that Medicare carriers will be most vigilant in the first half of the year in an attempt to bring you into compliance by the end of the year.
Not sure what they are looking for? You might begin by reviewing a couple of our past posts such as the Top 5 Errors Chiropractors Make in Medicare or Why Medicare Will Continue to Audit Chiropractors.
Even better, protect your practice by spending the day learning how to do Medicare (and regular insurance) correctly so you can bulletproof your business AND boost your bottom line. There’s still time to catch our upcoming ChiroProgress Seminar where we will be teaching just that – better Medicare, better insurance and better business strategies for 2017 and beyond!