This DISEMPOWERS us as a profession!
So HERE is MY story:
My largest insurance carrier asked me for 6 months' worth of notes on 10 patients going back almost a year prior. (I was lucky: dozens of colleagues were audited in Virginia that year, and some offices had to supply up to 30 patient files) My staff printed out almost a thousand pages of notes. I read through every single page. TWICE. And I did NOT like what I saw.
It actually looked, shall we say, less-than-stellar when printed out. TRY IT: it's called a "Self-Audit." And almost NOBODY does them. I would highly recommend that you do this BEFORE the real thing hits you.
My notes were filled with conflicting information. Huge swaths of text "SALT-ed" over from visit to visit, which made it hard to see where I HAD put in hard work. Lots of required information and "carrier documentation protocol" elements that I NOW know should have been there...wasn't.
Which I NOW know is the WORST thing you can do IF you know that you have documentation problems: doing nothing about it while you wait to hear back from the carrier while you hope that things will be OK. Things did not go well in the Spring of 2018 when I received my "Audit Findings" phone call (which I was utterly unprepared for, BTW).
BEFORE anyone gets all "Shame-y" and "Judge-y" about that, READ my 5/21/2020 Blog post "Why YOU would <probably> FAIL an AUDIT."
IN ALL FAIRNESS: When ANYONE is audited, your audit will go back at least year before your audit findings phone call. By the time I was placed on "Pre-payment Review", it was based on what my documentation was like 1 1/2 YEARS PRIOR, not their current state....before I had implemented many updates. If YOU are audited, the same will apply: ALL THE MORE REASON to fix things NOW.
I had THREE WEEKS to get my documentation in even better shape. I spent dozens of hours watching my EHR training videos, updating my macros and fixing content in my documentation, changing office policies, and educating my staff and patients. MANY nights I went back to my office after putting my daughters to sleep and stayed there PAST MIDNIGHT. It was HORRIBLE.
But I DID IT.
(I do NOT recommend this as a compliance strategy, by the way)
All ongoing services that you provide to that carrier's insureds are required to be submitted on paper claim forms, along with all printed documentation relevant to that visit. IF the carrier determines that the documentation does not support the carrier's definition of "Medical Necessity" AND meet all of their documentation parameters, they will deny the claim and not pay you. The carrier may -- or may NOT-- be forthcoming about the exact reason WHY those claims were denied.
AND...you are required to continue offering care to the carrier's insureds, because you are contracted to do so. (yes, this means what it sounds like: if your claims are denied, you won't get paid, yet you have to continue to provide services to those patients.
That was BEFORE I implemented any suggested changes.
IT DIDN'T MATTER. When you hear *anyone* say "as long as you show 'due diligence' " or "if you are demonstrating an effort to improve your notes and you'll be OK," THIS IS NOT TRUE.
Yes, you may appeal those claims. But this will takes months. Or years.
In Spring 2020, I am still fighting for over $10,000 in unpaid services that were erroneously denied.
it slowed my cash-flow from 75% of my practice down to a trickle... for SIX MONTHS. This was financially devastating to my practice and my family. The carrier had the upper hand, and myself and my colleagues in Virginia had little guidance on how to properly respond. And when it was clear that things weren't as fair as you would hope they would be I didn't know how to fight back. The AUDIT ultimately forced me to sell my office.
IF you decide to ACT and FIX THIS. NOW.
NON-COMPLAINT DOCUMENTATION is a HUGE problem, not just for Chiropractors (over 1/3 of all DC's), but for other healthcare providers* to the tune of BILLIONS of dollars. Don't think carriers are going to close their eyes and you can continue to fly under the radar!
Want to know a Dirty Little Secret? MOST Chiropractors (and docs of most health disciplines) HAVEN'T READ THEIR CARRIER GUIDELINES. Going to a workshop is NOT enough. It's NOT as scary as you think. Let's GO:
FINALLY create compliant provider EHR documentation and don't worry about not getting paid due to an audit EVER AGAIN.