When you are audited or have your claims reviewed here are some fighting tactics that are effective and easy to use:

  • Check out their credentials. You may be shocked to find out that your auditor or IME has absolutely no qualifications to review your claims, other than the need or willingness to take a check from the Insurance Company (or Third Party Administrator). Insurance companies routinely deny or demand repayment based on codes that contain high error rates (For example, 97140 or 97112).
    However, just because an auditor says you used them incorrectly doesn’t mean it is necessarily the case. After all, does he have enough experience with chiropractic to know how you are performing the procedure, is he a certified coder who can adequately judge the usage, or is he simply acting on statistical norms and assuming you are wrong?
  • Don’t write a letter asking for your research to be considered, demand that the reviewer/auditor be a licensed chiropractor in your state. This will automatically kick aside the DC who sits in his comfy chair across the country performing paper reviews on his unsuspecting colleagues. This also gives the boot to the nurse who is making a nice income auditing chiropractic claims despite the fact that she has no technical knowledge of chiropractic.
  • Demand that the reviewer be in active practice and that they do not derive the majority of their income from performing reviews or audits. I like this step because it really levels the playing field. After all, not many reviewers are going to bite the hand that feeds them – especially if that hand gives them most of their food! You are much better off being judged by some chiropractor who is trying to make an extra buck or feels some sort of moral obligation to cleanse the profession of the crooks and therefore performs audits on the side, but still gets most of his money from practice.
  • Demand to see the actual notes of the reviewer/auditor – not just the final summary. I have seen too many clients get out their checkbooks to write the insurance company a check for a failed audit when they have not examined the details of what made them fail. The average audit tool contains 18 items — wouldn’t it be nice to know which ones were at fault so you could correct them or (even better) dispute them?! Get the specific records reviewed, treatment dates, and what specific items were at fault or substandard.

By Tom Necela, DC, CPC, CPMA, CCP-P