Medical Review Policy Is Your Friend


:dropcap_open:I:dropcap_close:t’s the kind of phone call no doctor wants to receive. This particular doctor vaguely remembered the representative from the insurance carrier asking questions several months ago about some of the procedures performed in the office. She also vaguely remembered a request for some charts from this same carrier. Now, on the phone, she was being told that more charts would have to be reviewed and it didn’t look good. “How can this be?” she wondered out loud. “I’ve been getting paid properly, had no red-flags, and didn’t even know there was a problem,” she further mused. What was about to unfold seemed too unbelievable, and yet it was happening in living color. 

The reimbursement request was a simple letter on carrier letterhead. It laid out in detail all of the billing and coding violations they felt this doctor had committed. This company used a process called “extrapolation”. They performed some mathematical equations. The determination was that if the chiropractor made these errors on this group of reviewed files, then the insurance carrier could calculate errors in ALL the services in these categories provided over the last four years. If we apply this math, including the amount of money paid for these services over time, multiplied by the error rate, the doctor was getting a bill for several hundred thousand dollars! I know, right?? Holy Cow!

Fortunately, this doctor’s malpractice insurance had a clause for audit coverage within the policy. She was grateful because this coverage provided for her attorney’s fees and costs. Now she felt that she had some support in fighting the system. We rolled up our sleeves as a team and began looking at the allegations. Here is a list of some of the concerns:

1. The office provided massage therapy and it was delegated to a licensed massage therapist. Because it was not performed by the doctor all of the payment for the services had to be refunded.

2. Several therapy procedures, like electric muscle stimulation and traction, were also in question, based on the type or location of service.

3. Evaluation and management services were billed on the same date as chiropractic manipulative treatment services. Although this was only periodically, obviously for real examinations, the carrier felt there should be no coverage.

Wait a minute! Who sets these rules? How’s the doctor supposed to know about these rules? Doesn’t my state scope of practice allow me the opportunity to delegate services to properly trained individuals? As you can imagine, all of these questions went through our doctor’s mind. We found the answer in the medical review policy located on the carrier’s website. This particular carrier clearly indicated that massage therapy was a covered service, but was not covered when it was rendered by someone other than the chiropractor.

Because the services had been delegated, the carrier felt it was appropriate to ask for a refund of all of these payments. The electric muscle stimulation policy was also located on the website. Although this is a seemingly ridiculous policy, and in fact it was changed shortly after this audit took place, it did say that 97014 was only covered in an inpatient setting. The evaluation and management services issue was easily refuted. There is tremendous information available through the American Chiropractic Association and other coding authorities that have allowed us to educate this carrier on what’s appropriate.

This doctor’s woes are not quite over yet, as the case is ongoing. There is much review that needs to be accomplished. Can you be sure that you could pass such an audit? It is imperative that each and every chiropractic practice clearly understands the agreements that have been made when participating in a managed care or preferred provider organization. Even in an out-of-network situation, medical review policy must be followed. Simple online or telephone verification techniques are not enough anymore. The following processes should be included in every office’s standard operating procedure for billing compliance verification:

1. Review your provider agreements with every organization that you participate with. Look for specific language that rules coverage, tells you who can provide what services and offers medical necessity definitions and other particulars.

2. Study the medical review policies on the carrier’s website that govern the various services that you provide in your office. You can often search by code or by specialty. If you provide traction with a roller table, for instance, make sure that it isn’t specifically excluded under the policy. And if it is, find out if you are allowed to do it and charge the patient cash! This may also be forbidden.

3. Double-check the national coding policy for the most common services you render to be sure you’re spot on with your documentation of medical necessity. Be ready to appeal or defend denials that don’t make sense. You deserve to be paid for what you do, as long as it meets the guidelines you’ve agreed to by policy or by contract.

:quoteright_open:Double-check your malpractice insurance to be sure that you have coverage available should you be audited.:quoteright_close:

We can all use a nudge, a reminder, or a wakeup call to avoid the status quo. Remember, when you’re billing a third party payer for services in the office, they get to dictate, to a large degree, the level of reimbursement. When you receive denials for medical necessity, remember that you must appeal them. Otherwise it appears that you are in agreement with their denial. Double-check your malpractice insurance to be sure that you have coverage available should you be audited. Don’t live in fear! Be prepared! He who has the most information wins! 

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at 888-659-8777 or [email protected]

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