Red Flags under Chiropractic Medical Billing you need to Watch Out For?


Exploring or examining the numerous unpaid or denied claims is an exasperating and time-consuming process. On an average, more than 25% of the revenue loss faced by healthcare facilities occurs due to poor medical billing and revenue cycle management. According to the research report presented by Medical Group Management Association (MGMA), the average cost of reworking a claim is between $25 and $30. And as a hard working chiropractic practitioner you don’t want to lose this income due to some medical coding issue.

Closing these gaps or getting them streamlined requires up close and personal attention to patient data, treatment and diagnostic codes, and changing billing guidelines and insurance regulations.

Accurately taking down all the details, so that your chiropractic claims get submitted and paid correctly on time, is a challenge for many practices.

 Most of the healthcare payers are obligated to perform routine reviews of claims submitted by providers, who operate under their plans. In last few years these claims inspections have gotten more rigorous, with fraudulent activities on the rise. There are initiatives being pushed by private health plans and those operating under the umbrella of CMS. The occurrence of insurance fraud has created a hyper vigilant culture where all reimbursements are examined, to an extent, seeking the presence of fraud.

The caution displayed by CMS and private health plans is not unwarranted as the along with chiropractic specialty the healthcare industry loses billions of dollars annually due to these frauds. Sometimes they are intentional and sometimes driven by ignorance.

Chiropractic medical billing fraud in particular has presented itself as a growing issue within the healthcare industry. Chiropractic facilities operate differently than providers in other specialties, with highly specific care being delivered to patients. Due to this specification, there are a number of factors that could flag a chiropractic practice for a clinical documentation and claims review.

Insurers gather data about physician and provider profiles, an accumulation of data that sets a precedent and signals insurers to any variation from a typical medical billing pattern. These profiles are then put together in such a manner that if a practice doesn’t fit into the carefully selected categories, they may be flagged for possible fraud.

Here are some commonly occurring Red Flags for Chiropractic Billing

  • Failure to demonstrate medical necessity
  • Using “canned” diagnoses on patients
  • Identical care plans and procedures for patients with varying needs and diagnoses
  • Down-coding, which can still grab an insurer’s attention because it disrupts the expected billing distribution pattern
  • Inordinately lengthy treatment for conditions
  • Routinely practicing outside of the common geographical region for similar providers
  • Performing tests that aren’t commonly performed
  • Performing tests that are not identified by CPT codes
  • Using complex CPT codes to describe otherwise routine care

Medicare, for instance, is looking for providers to bill a certain amount of CPT codes for procedures such as 98940, 98942. This often requires 5 regions of the spine included in the diagnosis to substantiate usage, and 98941. If a provider is billing 80% with 98940, they may be flagged for review.

However, the good news is that there is a way around raising those red flags. First thing you good do is to educate your medical billing and administrative staff on accurate CPT codes and procedures is the first step. Or else you can hire a specialty chiropractic medical billing company who has all the expertise in looking for those red flags. Following the rules and requirements established not only by private health plans, but by CMS, will safeguard that the audit process goes smoothly for your practice.

Remember to stay current, stay updated, and always confirm that your procedures and CPT codes are according and easily substantiated for each patient, and for each visit.

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