Exploring or examining the numerous unpaid or denied claims is an exasperating and time-consuming process. On 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 the 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 issues.
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 the 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 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 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.
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. The 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. To know more about our Chiropractic Medical Billing services, contact us at info@medicalbillersandcoders.com/888-357-3226.
FAQs
1. Why are unpaid or denied claims a problem for chiropractic practices?
Unpaid or denied claims can lead to significant revenue loss, with over 25% of losses attributed to poor billing and revenue cycle management.
2. What factors contribute to claim denials in chiropractic billing?
Common issues include failure to demonstrate medical necessity, using generic diagnoses, and discrepancies in treatment plans for different patients.
3. How can chiropractic practices avoid being flagged for fraud?
Practices can minimize risk by ensuring accurate documentation, using appropriate CPT codes, and adhering to billing guidelines set by insurance providers.
4. What should chiropractic practices do if they frequently face claim denials?
Educating billing staff on coding accuracy or hiring a specialized chiropractic billing company can help ensure claims are submitted correctly and reduce the chance of denials.
5. What are some red flags that might trigger a claims review?
Red flags include down-coding, lengthy treatments for simple conditions, identical care plans for diverse patients, and unusual billing patterns that differ from industry norms.
