Have You Recieved Your Medicare Audit Letters Yet?
I am hearing from many of my clients and some billing and coding professionals that I know that Medicare has stepped up its audits and reviews on chiropractors.
Medicare carriers around the country are sending out these audits as part of President Obama’s Executive Order # 13520, “Reducing Improper Payments and Eliminating Waste in Federal Programs.” The goal of this order is to eliminate payment error, waste, fraud, and abuse in Federal program and requires federal agencies to conduct semi-annual studies to identify and reduce vulnerabilities in high risk areas.
This is happening right now, it started in mid-August 2010, Medicare carriers will begin increasing their recovery efforts and sending piles of CERT (Comprehensive Error Rate Testing) letters aimed at chiropractors. Although the program is not targeting chiropractors specifically (all Medicare providers are under similar attack), they have made the chiropractic targets public knowledge. Chiropractors who meet the following criteria will be subjected to “random” audits:
- Chiropractors who have submitted multiple claims for the same Medicare beneficiary between April and June 2010
- The CERT audits will focus on determining whether chiropractic services billed to Medicare were medically necessary as acute (active) chiropractic treatment.
- For each claim selected, CMS will review medical records up to 12 months prior to the date of service on the claim.
Based on the “random” criteria listed above, CMS will deny claims for services that the reviews have determined to be maintenance and not active treatment. Accordingly, the Medicare carrier will then take steps to recoup any over-payments.
From my experience with chiropractors I would guess that these CERT criteria will apply to just about every chiropractor in the country.
According to data published by Medicare in the press release for this new CERT launch, Medicare is going after $174.1 million in projected improper payments to chiropractors. Taken across the board, that $174 million could mean every DC in the country would be forced to cough up roughly $3500. Since a sizable chunk of DC’s on record are practicing part-time, retired, or not practicing at all, it’s possible that the 50,000 DC pool is much smaller. In half, that would mean $7000 per DC. Frankly, some of you don’t have anything to worry about because you see Medicare patients once every blue moon. This conceivably can chop the available audit pool in half again, leaving all the remaining DC’s to foot a $14,000 bill.
If you are still reading and are concerned, here are a few brief recommendations to tackle this issue with a sober mind and some strategic planning:
- The worst mistake is to ignore the CERT audit request. You have 30 days to comply. Do it quickly. If Medicare deems your documentation, billing or coding unworthy, they will ask for money back. If they don’t even receive your documentation, they will still ask for their money back AND they can pursue the opportunity to charge you with fraud.
- Medicare has stated that the primary causes of the errors were payments for maintenance therapy and missing plans of care. Two recommendations here: (1) if it walks, talks, quacks like a duck, it’s a duck. When Mrs. Jones comes in like clockwork every first Monday of the month, with no rhyme or reason other than, it’s her scheduled appointment, it’s going to be a long hard road to prove that this visit is not maintenance. (2) Include a plan of care! Some docs mistakenly think that they are flying “under the radar” by not documenting any scheduled visits. If it’s PRN, say it’s PRN! If you want them to come in 3x over the next 2 weeks, state that! And remember, a treatment plan is more than a schedule of care (but that’s another topic for another day)
- Seize the opportunity! Scared? Some of you should be! But being afraid accomplishes nothing. Face your fears and fix your shortcomings! Get help instead of sitting there wondering if the Medicare monster is going to eat you for lunch. No third party payer – Medicare included – expects your notes to be perfect. Your documentation should meet standards and if you want to keep yourself out of trouble, it should look better than your peers. Why? Because, statistically speaking, many of your peers are getting it wrong – which is why we are in this mess in the first place.
The Final Word
For those of you who are feeling a bit paranoid, persecuted or just plain peeved, take heart: Medicare is not trying to eliminate chiropractic. What they are trying to do is to clean up errors within their own systems – for physicians of all types – and in the process, reclaim money that should not have been paid out in the first place. It may not seem fair that they have “suddenly” raised the bar. In actuality, the rules were there the whole time; they have recently taken the opportunity to enforce them.
And yes, it’s about the money. When a cash-strapped government entity discovers that it can recoup $900 Million in incorrectly paid claims in about three years time, it wants to repeat that “experiment” over and over again. If you haven’t been paying attention, that’s exactly what happened starting in 2005. And the nearly $1 billion recovered was not just from chiropractors. In fact, we are only a small piece of the pie. Unfortunately, the coffers are so empty, the powers that be want to scrape up every penny they can get back.
We do have the ability to defend ourselves here. First, we can make sure our chiropractic billing, coding and documentation is as bulletproof as possible. Then, our best defense will come in the fact that Medicare (and every other third party payer) may take a few pennies back from the chiropractic community, but it will cost them a few dollars to do it!
