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How to respond to an Insurance Audit by smithhaleey


									                      How to respond to an Insurance Audit

Why do insurance audits occur?

      1. The use of an unusual Code

             A. A chiropractor using a 99204 for an ankle sprain

             B. A chiropractor using a surgical code

             C. A consultation code

      2. An unusual Profile compared to peers

             98942 above 5%

             98941 above 40%

             99204 exam frequency

                                                                   Section 4 Page 1
      Unusual Code frequency

      Unusual treatment length frequency

      Unusual frequency of accidents

      Discovery by company of improper payments based on industry

3. Patient/employee/spouse Complaints

                                                                    Section 4 Page 2
Purpose of the Insurance Audit

      1. To determine if payments have been made correctly

      2. To determine if fraud had been committed

      3. To change provider billing methods if incorrect.

How to make it through an insurance audit

      1. Be very cooperative

      2. Have the records reviewed independently that are being requested, prior to
         sending the records

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      3. If onsite, be very nice and accommodating

Negotiation Techniques

      1. I did not realize I was doing that wrong, I will never do it again

             a. Be fully cooperative and amenable to change

      2. Negotiate settlement amount

             a. negotiate amount they want

             b. Negotiate an offset

How to avoid an audit

      1. Periodically Audit yourself

                                                                              Section 4 Page 4
              a. Do a compliance Audit in each area of billing 2 times per year

       2. Totally understand every code you are billing

              a. Use what sales people tell you as a guide

              b. Verify every code you use

       3. Bigger practices

              a. Have a compliance audit by an outside source

If Things go sour

       1. Bring an attorney into the picture at the first sound of a fraud accusation

              A. Attorney must be a specialist in Health Care and Compliance Law

                                                                              Section 4 Page 5

            Section 4 Page 6

I. Case Records

       A. The Basis for Your Report

II. Philosophy

       A. The Report Is Used To Educate and Serve Notice

                 1. Adjustors

                 2. Patient’s

                 3. Attorneys

       B. The More Technical, the Less Understood

       C. Purpose of Report

                 1. Educate

                 2. To Get Paid

                 3. To Aid Other Physician’s In Treatment Decisions

                 4. To Aid In Gaining Other Physician’s Referrals

                 5. To Avoid and Prevent Malpractice

                        a. Parts of the body

                        b. Treatment

                        c. Treatment plan

       D. A Physician Is an Observer and a Reporter Of Fact

                 1. Neither an Advocate nor Antagonist

                                                                      Section 4 Page 7
III. Style

        A. All Different

               1. Personal Injury

               2. Worker’s Compensation

               3. Insurance

               4. Other Doctors
                          If going to a referral doctor – get back to them by fax
                             within 24 hours
                          If sending a patient to another doctor, send so they have at
                             least 1 day before patient’s appointment.

               5. Short/Medium/Long

        B. What Not To Write

               1. Personal Comments that Have No Bearing On The Case

               2. Patient’s Negative Demeanor or Attitude

               3. Do Not Paint Yourself into A Corner

               4. Routine Phrases

                      “Garden variety accident”

                      “The usual tests”

                      a. Every PI Case may have a lawyer and go to court

                      b. What’s Routine?

                              1. Everyone is different and individual

                                                                               Section 4 Page 8
       C. Interim Reports

IV. Important Things to Write

       A. A History That Clearly Explains the Basis For Injury

       B. Helpful Examination Findings

      C. Comments about Family Relationships That Have Been Disrupted When

       D. Analysis of Other Health Care Providers Whose Reports You Have Received

       E. Items That Show Damages

V. How to Write the Narrative Report

       A. Increase Readability and Understandability

              1. Use Simple Terms Instead of Technical Terms When Possible

       B. Buzzwords

              1. Accident vs. Collision

              2. Complaints vs. Symptoms

              3. What Patient’s Say

                      a. In their own words vs. your words

              4. Grinding, Burning, Numbness, Swelling

                      a. Common words that paint a picture when possible

       C. Visual Descriptions

              1. Bruises

                                                                             Section 4 Page 9
                      a. Size of a half dollar

                      b. Black and blue

                      c. Polaroid Camera

                                 2. Enclose Charts When Helpful

               3. Explain Tests and Their Significance

               4. Refer To Liability

                      a. Causal Connection

               5. Detail Of Accident

               6. Do Not Seem Canned

               7. Any Supportive Devices Used in Treatment And Relief Of Pain

               8. Reasoning - Used For Settlement

                      a. Prognosis/Diagnosis

VI. Specific Parts of a Report

       A. Introduction

       B. Patient’s History Of Accident

       C. Present Symptoms

       D. Past History

       E. Examination

       F. X-Ray Interpretation/ Lab Reports

       G. Diagnosis

                                                                          Section 4 Page 10
       H. Treatment

       I. Restrictions

       J. Prognosis

       K. Closing

VII. Stock Reports vs. Original Reports

       A. Okay to Structure a Report

              1. Cannot Sound Like All Your Other Reports

              2. Good Lawyer Will Subpoena 10 - 20 Files

VIII. Problem Areas

       A. Who Is the Report For

       B. Why Is It Being Written

       C. Never Write “No PPD or Impairment

IX. Authorship

       A. Dictate Or Write Yourself

              1. Keep CA Out Of Report Writing

              2. You Have To Prove It

              3. You Have To Defend It

              4. You Have To Sign It

              5. You Have to Attest To It

                                                            Section 4 Page 11
Secrets of the CMS 1500 Claim Form

                                 Section 4 Page 12
Section 4 Page 13
Section 4 Page 14
For Claim Form Instructions go to
  Specifically at

                                                                                Section 4 Page 15
Key Points:

New version CMS 1500(8-05) should go into effect by June 1 st, 2007
Look for “Approved OMB-0938-0999 Form CMS 1500 (08-05)” at the bottom right of
the form.

Address to Insurance Company:

Upper Right

1st Line - Name                                       1st Line - Name
2nd Line – First line of address              OR      2nd Line – First line of address
3rd Line – Second line of address                     3rd Line – Leave blank
4th Line – City State (2 digits) and Zip Code         4th Line – City State (2 digits) and Zip Code

For Block 12 and Block 13 you can use Signature on File, SOF, or legal signature

Place of Service 11 Office, 12 Home

Block 31
Signature of Physician or Supplier
Can use Signature on File, SOF or actual signature.
This refers to the authorized or accountable person and the degree, credentials or title.

The form is the basis of making payment decisions.

How do you tell if a claim should be considered acceptable for a higher benefit level
(an accident)?

ANS: Block 10, Block 14, Block 21 with Primary diagnosis (1) 800 series.

How do you determine the proper level of chiropractic manipulation to allow?

98940 in Block 24 must have 1-2 areas in block 21

                                                                                  Section 4 Page 16
98941 in Block 24 must have 3-4 areas in block 21
98942 in Block 24 must have 4 areas in block 21 and additional diagnosis in upper part of
Block 24 line with 98942 in it.

How do you identify what a 99070 code is for?

Block 24 with 90070 must have description in upper half. Additionally, diagnosis must

CPT code 98940 and 97140 filed on same claim?
  1. –59 in block 24 modifier for 97140 block.
  2. Diagnosis of separate area from spine in 21 and pointed in 24 E
  3. Explanation above 97140 Block 24

How can you tell there is a new condition and that you should allow additional
          1. Change in Block 14
          2. Possibly new diagnosis in Block 21
          3. E/M code in Block 24
          4. Explanation above E/M code in Block 24
          5. Possibly Block 10

       Billing for an E/M code and a procedure

       1. –25 block 24 with E/M code
       2. Explanation in Block 24 with E/M code
       3. Reasons for E/M codes
             a. New condition
             b. Exacerbation of condition
             c. Significantly worsening condition requiring evaluation
             d. Significantly improving condition requiring evaluation
             e. Formalized Re-evaluation
             f. Qualified counseling

       Action Steps

Study Notes
When filing a claim, look at it as if you are a claims examiner. Does it make senses? If
not, what questions do you have and how can you answer the on the form.
Be sure all things are documented.

                                                                               Section 4 Page 17
Overcoming Claims Objections

                           Section 4 Page 18

Most Common Reasons For Claims Review
      1. Prolonged Treatment That Is Not Apparently Resolving The Condition
                    Demonstrate continual improvement
                          Pain Scales
                                  Visual Analog Scales
                          Pain Questionnaires
                                  Oswestry, Roland Morris, Etc.
                          Patient reports

                     Formally Re-evaluate
                           Demonstrate improvement

                     Change Treatment
                           Reduce Passive Care
                           Emphasize Active Care

       2. CMS 1500 Claim Form Not Filled Out Properly
                   Change CMS 1500 Claim Form Block 14 date with:
                          New conditions
                          Document Records

                     Change CMS 1500 Block 21 Diagnosis
                           When there is a new condition
                           Be sure matches documentation

                     Improper Codes
                           Understand ICD/CPT codes

                     Does the diagnosis and the code match?

       3. Continual Passive Care
                     Change treatment as patient progresses to more active form of
                             Patient Education
                             Alternative Approaches to Activities

                                                                             Section 4 Page 19
                           Be sure to document
       4. Unnecessary or Unusual Testing
                    Before doing any diagnostic test:
                           Determine why the test is necessary
                                  How will this test aid in diagnosis?
                                  How will this test aid in treatment determination?
                                  How does this benefit the patient?

       5. Multiple or Redundant Therapy
                      Understand what the proposed therapy does
                            How will this process enhance outcome?
                            Pre-type up an explanation of the therapy
                                   Be sure to comply with scientific rationale
                                   Add exactly how it is placed on the patient
                                   If time is a factor, add time (should include anyway)
                                   Add the rationale for treatment if appropriate

       6. Improper ICD or CPT Code
                     Read the introduction to ICD and CPT to fully understand their use
                            Use the codes properly
                            Be sure that your documentation justifies the codes utilized

      7. Unanswered questions or incomplete answers to questions
                   Be sure to answer the question posed.
                          You may have a staff member read it to see if it is


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