An insurance or work comp audit is a tremendously nerve-wracking and distracting assault on an entire clinic. When the letter arrives, everyone is taken off task to address the demands of the audit, and the entire practice suffers. Patients feel the pain as well, and thus begins a dangerous downward cycle with very real and lasting negative financial implications.
Insurance companies are increasingly performing post-payment audits on providers, and chiropractors are top among their ever-expanding targets. The chances are significant that nearly all chiropractors will, at least once, face insurance audits of their practices. This ritual scrutiny mandates that chiropractors take the offense, or they risk severe penalties. Among those is loss of license.
While avoiding audits is impossible, thorough and cohesive documentation is the only mechanism that will ensure a passing grade. Electronic documentation provides the only fool-proof modality to obtain comprehensive and immediately accessible records. It allows for the three key elements to audit-proof notes:
- accessibility
- subjective intake
- non-templated notes that meet the highest standards of compliance
According to Angelia Giordano-Powell, CPC, CCO, a healthcare consultant with more than thirty years of experience working with audit prevention, “Chiropractors must operate in full compliance with both their individual states and federal regulations and can do so without impeding the growth of their practices.” Failing to take every reasonable measure to comply with these requirements could result in serious consequences.
Given the cost-containment environment that governs insurance and state regulatory policies, it is likely that an audit would devastate any chiropractic office that has not taken the vital step of modernizing its record-keeping so that it is approachable and accurate.
Accessibility remains paramount to a practice being able to not only pass audits, but also to provide high-level patient care. The advent of current technology allows doctors and patients to communicate in ways previously unheard of. Caregivers across a wide spectrum are suddenly able to share valuable information and collaborate about specific patients’ health care needs. They are then able to collectively develop tailor-made goals and treatment plans. This coordination of primary care and specialists serves as a unique approach to total health care.
Similarly, rather than being bystanders in their own care, patients become active participants. This contributes to a better doctor-patient rapport and gives patients the confidence that they are receiving all information pertinent to their health. Having a digital road map of patient history and progress allows auditors to view seamless consecutive steps in the overall treatment, and verify that billed procedures were performed.
Web-based record keeping on a secure server is fast becoming the gold standard, and its accessibility and security are the primary reasons. Making records accessible on-line entails work in order to ensure security and HIPAA compliance. It also requires diligence on caregiver’s part to help patients who may not be comfortable with the web feel more at ease.
In June 2005, The Department of Health and Human Service’s Office of Inspector General released cumbersome report detailing the importance of conducting Medicare audits specifically on chiropractic offices. “Based on the volume of medically unnecessary, undocumented, and non-covered services allowed, chiropractic services represent a significant vulnerability for the Medicare program,” the report finds. When state, federal, and private insurance auditors review chiropractic records, they search for readily-available and complete documentation. Procedure codes and all components as required by state, federal, and insurance requirements need to be included. If all required components cannot be retrieved instantly, then the audited practice risks failing.
Among these components is comprehensive subjective intake. Health care providers continually neglect to document their patients’ description of their symptoms and condition. This step is crucial to passing audits and to assessing patient needs. Only the patients can provide a first-hand account of the symptoms that they have because they are the ones experiencing them. Doctors must document, on the spot, the descriptions their patients provide. Medicare Part B and other entities require that these subjective accounts be properly documented because caregivers’ decisions to order subsequent tests and procedures are largely derived from this critical element. Poorly documented information will possibly result in repayment measures because insurance companies want every treatment plan, test, and procedure to be deemed medically necessary. Chiropractors are increasingly becoming targets due to improperly recorded subjective notes.
Failure to properly document these can lead to sanctions, lawsuits, and charges of fraud. Further illustrating the intense effort of federal agencies to curb improperly documented records, the Office of Inspector General also found that “though a documentation requirement, chiropractors infrequently developed treatment plans for their Medicare patients. Just 28 percent of chiropractic services were provided as part of a written plan of care, and only 23 percent of those plans included specific treatment goals and objective measures to evaluate progress towards those goals. The absence of specific goals was a strong indicator of unnecessary care; only 14 percent of services associated with specific, written goals were medically unnecessary compared to 61 percent of those without written goals.”
The term “medically necessary” has become the thorn in many caregivers’ sides. Health care providers have long argued that they and not insurance companies or government agencies should determine how to care for their patients. The reality, however, is that providers are required to abide by the policies these entities have laid out within their scope of practice. Proper documentation reveals the step-by-step process by which health care decisions are come by. Digitally tangible records aid chiropractors in making their cases to auditors that patients require particular treatments. They will have, at their fingertips, the clearly laid out reasons.
Another vital part of keeping compliant and comprehensive records is the use of non-templated notes. Computerized or templated notes are not acceptable and would almost assuredly lead to failing an audit. They do not contain quality narrative remarks that explicitly delineate patients’ symptoms, conditions, and treatment plans. Often, and somewhat embarrassingly, they lead to very poorly structured paragraphs, with misspellings or grammatical errors hard-coded into the template. A doctor's inability to edit his own notes due to the limits of templated software is a costly problem!
Chiropractors and other caregivers have been guilty of using these generically templated notes as opposed to substantively and completely relaying pertinent patient information. This is an integral step to remaining compliant. Templated macros are insufficient because they are not tailored to the unique attributes of each patient’s condition. Patients are not cookie-cutter sets of symptoms. They have varying backgrounds, habits, experiences, family histories, and most importantly, different bodies. As such, plug-in analyses do not cut the muster. Chiropractors, who already face concentrated inspection of their practices, must be especially careful to describe patients’ conditions, plans of care, and progress. Patients do not need test A simply because they purportedly have symptom A. Insurance companies are beginning to sanction providers who use these non-narrative, templated notes. They also reject them outright.
Powell says, “A total compliance solution reduces liabilities, minimizes exposure to audits, and prevents regulatory investigation.”
Being proactive, conscientious, and diligent will allow chiropractors to avoid dreaded audits when possible and easily pass them in the event that they occur. Audit-proofing one’s notes is easy. Becoming compliant is easy. However, given the current cost-containment climate, changing to electronic record-keeping is no longer optional. It provides the accessibility that is required. Further, that electronic system should be capable of accommodating all compliance components. It is particularly critical that it be capable of allowing chiropractors to produce substantive, narrative notes and include subjective intake. While web-based documentation is relatively new, it is quickly becoming the norm. Substantial parts of banking, business transactions, and even legal documents are all done electronically. Electronic recordkeeping is simply a vehicle to achieve the unequivocal compliance that federal, state, and commercial entities mandate.
In President Bush’s 2004 State of the Union address, the President said, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” He began a 10 year plan to convert Americans’ health records to secure electronic records. He and health advisors recognize how vital this move is because it allows for important information to be shared among providers so that patients benefit. While avoiding and passing audits serve as motivators for converting to electronic documentation, chiropractors and other caregivers must conclude that the benefits to patient health primarily requires such a transition.
Facing an audit is scary and stressful. Auditors are trained to find and deliberate about pursing every impropriety and omission. Compliance does not have to be the daunting task it appears to be. In fact, total compliance, as Powell, points out, must be the goal. If chiropractors fully comply with requirements, then they will not be rendered helpless and subjugated to the consequences of an auditor’s scrutiny. By taking the appropriate measures to backup their choices when it comes to caring for their patients, chiropractors protect themselves and their patients.
sarah grupper
