Surviving the Scrutiny: New Efforts to Expose Fraud
and Recover Overpayments Puts Health Care Providers
Under the Magnifying Glass

This section was compiled by Frank M. Painter, D.C.
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Thanks to ACANews for permission to reproduce this article, exclusively at Chiro.Org!

By Nataliya Schetchikova, PhD,
ACA News Assistant Editor

You’re not imagining it. All of health care, including Medicare and private health plans, are watching you—closely. The search for fraud in health care reimbursements has heightened in the past few years following the release of studies showing high rates of errors and omissions among claims, leading many to suspect fraud. Like it or not, payers are now more likely to view even innocent billing errors as possible fraud.

While most physicians don’t set out to commit fraud, a few “bad apples” cast a shadow on the rest of the industry. A coordinated effort to combat fraud, mandated by Congress, has prompted many states to reinforce anti-fraud laws and private insurers to create fraud detection mechanisms. The National Health Care Anti-Fraud Association estimates that at least 3 percent (or $51 billion) of the 2003 U.S. health care expenditure was spent on fraudulent claims.   Others estimate the yearly number at as high as 10 percent.   [ 1 ]   “Doctors who may simply inadvertently and innocently bill using an incorrect code can sometimes end up in this mix of ‘fraud’ enforcement,” says attorney Tom Daly, ACA legal counsel.

If your documentation and coding are in order, experts advise that a review shouldn’t pose a problem. The 2005 HHS Office of the Inspector General (OIG) report, however, warned that 94 percent of chiropractic records are missing or inadequately present some key elements — evaluation, a treatment plan, medical necessity, and/or contraindications to treatment. As a response to the report, Medicare’s Comprehensive Error Rate Testing (CERT) reviews, which used to look at one date of service only, are now reviewing six months’ worth of records, says Ritch Miller, DC, ACA’s Medicare Committee chairman. “It’s a huge change, and we are starting to see doctors under a lot closer scrutiny and scrambling,” he adds.

      Is Your Practice Flagged for Review?

Because carriers are obligated to check random claims, no one is protected from the possibility of a review. Certain treatment and billing practices, however, can—and do—flag providers as candidates for reviews, audits, and investigations, experts tell ACA News.

“Insurance companies have their own physician profiles, and anything that takes you out of the regular curve of billing can set up a red flag,” says Jonathan Griffiths, DC, DABCO, DABCC, who worked as a consultant for Alabama Blue Cross Blue Shield for four years.

Although physician profiles differ depending on the insurer, there are common areas, explains Pat Jackson, a former ACA vice president who directed the association’s insurance initiatives. She suggests that doctors ask themselves the following questions to gauge whether their practices might raise insurers’ eyebrows:

  • Do you routinely practice outside of what others in the geographic area do?

  • Do you perform tests that no one else performs?

  • Do you perform tests not identified by a CPT code?

  • Do you treat patients more than once a day?

  • Do you routinely use complex CPT codes to describe care?

  • Is your diagnosis accurate? Can it be substantiated?

  • Do you routinely use the same diagnosis on every patient, or what insurers call “canned diagnoses”?

Sometimes insurers are especially suspicious of certain procedures or tests, she adds. “Right now, mobile diagnostic testing and multidisciplinary practices are on the list,” says Jackson, who worked in the insurance industry for 23 years. Although multidisciplinary practices are a good way for patients to get all the services they need in one place, insurers may review the practice for possible overlap of services caused by spreading responsibility for patient management among several providers, she says.

ACA has a policy statement available that provides questions that DCs should ask themselves before entering into mobile diagnostic services agreements. In general, “when a group seeks to use your provider number, be prepared to ask very pointed questions,” advises Bobby Gibson, operations director of ACA’s Insurance Relations Department.

      Problematic Billing Patterns

Patterns in treatment and billing also make third-party payers frown, experts explain. “Insurers believe that each case should be very patient-specific. Providers shouldn’t be treating every single patient the same- no matter the age, complaint, and other factors-it raises a red flag,” says Gibson. “With every patient, all providers are expected to have a case-specific goal and a treatment plan,” he adds.

Computer programs have made it easy for insurers and Medicare carriers to spot claims that deviate from the norm, says Susan McClelland, ACA Medicare and coding advisor. “For example, in Medicare the carrier expects to see you bill a certain percentage of 98940s, 98941, and 98942s. If you are billing 98940 ninety percent of the time, it could cause an investigation. People think that downcoding won’t bring a carrier’s attention, but it violates an expected distribution pattern,” she says.

A doctor who sees a lot of Medicare patients may also prompt an overall utilization review, says Dr. Miller. This doesn’t mean, however, that the doctor is doing something wrong, but the payer will look at aberrancies, he adds.

      Follow the Rules

The good news is, if a doctor is following the rules, a review or an audit should be relatively painless, agree the experts. “If you have proper diagnosis and use proper CPT coding, you have very little problem with fraud and abuse,” agrees Dr. Griffiths. “When you try to play the game of insurance companies by using the codes that are not appropriate, spending inappropriate time with patients, or carrying the treatment program for longer than the natural history would dictate, you have a problem.” As an example, he explains that uncomplicated low-back pain generally gets better by itself in four to six weeks, so a provider who sees a patient for the condition for six to seven months (without any significant co-morbidities) will be a more likely review candidate.

Best clinical practices are about “treating and billing what’s in the patient’s best interest, using your own diagnostic abilities rather than relying on extensive tests, and knowing when to stop care and how to move the patient into a system of self-care and not promote dependency on the provider,” agrees Jackson.

“If there is no progress toward the goals outlined in the treatment plan, a change needs to be made. Either alter your treatment plan or refer the patient out,” says Laurie Douglass, ACA’s current vice president of insurance relations. She says that improved documentation would resolve most of the red flags raised on chiropractic claims. Some problems with insurers, however, lie in their misunderstanding of how chiropractic works, and ACA works to educate insurers about chiropractic care, she adds.

Providers should not rely on weekend seminars as the only source of information on how to run their practices, says Jackson. Although seminars can be helpful, some information they teach may not be applicable to all states, she adds.

Especially questionable are seminars or groups that promise to teach doctors to bill for more money. “When it comes to billing insurers, you need to be careful whom you take billing advice from,” says Kara Murray, ACA’s insurance advocacy manager.

Jackson agrees. “[By attending] seminars or workshops that promote financial gain over what’s best for the patient, you are buying a free ‘go to jail’ card,” she says. For example, billing for an E/M code one day and bringing the patient back the next day to review the report of findings may be considered manipulation of the patient for financial gain, she explains.

      More “Hot Water” Areas

In addition to inconsistent and improper billing, health care providers can be reviewed or audited because of “complaints by patients, existing staff, former staff, peers, the general community or because of offering kickbacks or inducements,” says Dr. Miller.

The rule of thumb, explains ACA Legal Manager Jaime Mulligan, is that a doctor cannot necessarily offer incentives to one group of patients without violating the rules of another group. If, for example, the doctor offers a discounted or free exam or x-ray to a new cash patient but not to patients with insurance coverage, the insured patient is technically paying more than other patients, and that raises red flags to insurers. Moreover, offering free or discounted services to a Medicare patient to induce payment for CMT services can be a problem—the federal government views this as inducing patients to possibly unnecessary care, she stresses.

Waiving—or not attempting to collect—a deductible or co-pay as a regular course of business may also cause problems. Some exceptions exist in cases where the money spent to collect the deductible would exceed the amount of the deductible itself, or where financial hardship on the patient is determined, says Dr. Miller.

If doctors do offer waivers to patients who experience financial hardship, they must offer them to all patients in the same circumstances, to avoid discrimination, says Douglass.

To protect yourself, notify the carriers of the waiver, advises Daly.

      “I’ve received a review notice. What do I do?”

If, despite your best efforts, you have been flagged—or randomly selected—for a review or an audit, don’t panic. It’s in your power to help the process go as smoothly as possible.

The general recommendation is to cooperate and communicate. “Audits are allowed in a contractual agreement between the doctor and the insurer, so the doctor should give the auditors every opportunity to enter the office and look at files,” says Dr. Griffiths.

Jackson agrees. “Resistance and fighting the system are viewed as if something is being hidden. Give the insurers what they need, and, if you can, sit down and talk with them about what the basis is for the investigation,” she says.

For a list of tips on how to present your records to reviewers in the best possible light, see the sidebar below. For DCs to understand what commonly happens in investigations, the ACA has developed a public policy on insurance.   [ 2 ]

If you believe the results of your review are unfair or inaccurate because your documentation is in good shape, you can file an appeal with your state’s department of insurance, says Murray.

Medicare has its own appeals process, notes McClelland. And, again, to win in an appeal, documentation must be complete. “You’re required to have certain things in your notes. When you submit a Medicare claim, you’re [certifying] that you have all the necessary documentation-otherwise you have submitted a ‘false claim,’” she says.

To survive the scrutiny in the future, stay away from anything that looks like fraud, and if you suspect that something may be fraudulent, it probably is, advises Jackson. “If you want to get an accurate interpretation, check out state laws with your attorney or state licensing board. Do some homework so you don’t engage in something risky,” she adds.

Next Month: Fraud Compliance Programs

For More Information

  • "Coding Misuse Prompts Fraud Investigations":

  • ACA’s official policy on Mobile Diagnostic Services:

  • Fraud and Abuse Medical Review Benchmarks,

  • Medicare Audit Tips from Wisconsin Physicians Service
    (Medicare carrier for Wis., Ill., Mich. and Minn.):

  • Medicare Documentation:

  • June 2005 OIG Report:


1. A Serious and Costly Reality For All Americans. National Health Care Anti-Fraud Association. health care fraud

2. Public Policy on Insurance: Fraud and Abuse Medical Review Benchmarks. American Chiropractic Association. (Ratified by the House of Delegates, September 2004).

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