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Chiropractic Compliance Programs
By Howard Levinson, DC, CFE, AHFI
As of the end of 2008, five doctors of chiropractic and one medical doctor from the Atlanta area had either pleaded or been found guilty in federal court following an investigation involving the misrepresentation of claims submitted for spinal decompression and/or nerve block services.
In 2007, a New Jersey chiropractor pleaded guilty to defrauding a health insurance company by submitting claims for services not rendered. The doctor was ordered to pay back more than $14,000 in restitution, sentenced to one year of probation and received a three-year suspension to practice.
In 2006, a California chiropractor was fined $25,000 for false advertising related to spinal decompression services, and a Massachusetts chiropractor’s license was suspended for four years after he submitted claims for undocumented services, up-coding services, and continuing treatment after the patient reached maximum medical improvement.
In each of these instances, a breakdown in ethics, integrity and compliance with rules occurred. An effective compliance program may have prevented them.
In my experience, many doctors of chiropractic institute a compliance program only after they are ordered to do so as a result of an insurance company audit. In some cases, by that time, the damage has been done. The benefit of establishing compliance guidelines for your practice before an issue occurs is worth the effort required to put a program in place.
The Benefits of Compliance Programs
Compliance programs are designed to assist providers in preventing the submission of erroneous claims or engaging in unlawful conduct. Effective compliance programs help to assure that the doctor and staff know the applicable rules and regulations and provide a format for continuously following them.
In the early 2000s, the Office of the Inspector General (OIG) formalized voluntary compliance program guidelines for individual and small group practices.1 The components of a compliance program may include some or all of the following actions:
1. conducting internal monitoring and auditing of the practice
2. implementing compliance and practice standards
3. designating a compliance officer or contact person
4. conducting appropriate training and education
5. responding appropriately to detected offenses and developing corrective action
6. developing open lines of communication
7. enforcing disciplinary standards through well-publicized guidelines.
The foundation of an effective compliance program should foster the development of a culture of integrity, accountability and ethical behavior within the entire practice. This requires a commitment by everyone in the practice to support a compliance effort.
In a small practice, the doctor often has to take the lead. While it may not be feasible to institute all seven steps, the small practice should adopt those compliance program components that are most likely to provide a benefit based on the practice’s history with documentation, coding and billing problems, or other identified compliance concerns and that best suit the needs of the practice.
Monitor and Audit Your Practice
The provider should be able to define practice statistics, such as visits per patient and the number of services per visit, and be prepared to provide rationale for these numbers, if questioned. The doctor should periodically evaluate the coding for services and check that the documentation in the patient’s file supports the services provided.
Common problems discovered during an internal audit are failure to adequately document timed physical medicine modalities, inadequate documentation to support a high-level Evaluation & Management service, or lack of documentation for a multiple-region chiropractic manipulation service. Once identified, these problems can be corrected.
Conduct Appropriate Training
The provider should keep current CPT®, ICD-9 and HCPCS references available at the office. The provider and/or staff can also attend documentation and coding seminars offered through colleges and professional associations, or online. The doctor may find it helpful to consult with an attorney well versed in compliance issues or utilize a private consulting firm to audit the practice and identify areas of concern.
An effective compliance program can optimize payment of claims, minimize billing mistakes, reduce chances of an audit, enhance the practice’s ability to prevail during an audit, help the DC avoid conflicts with self-referral and anti-kickback statutes and reduce the likelihood of patient privacy complaints. And, ultimately, all of these factors help you better care for your patients.
Dr. Levinson is a certified fraud examiner, an accredited healthcare fraud investigator and a forensic chiropractor who currently serves as a clinical director for the Special Investigations Fraud and Abuse Unit at WellPoint Inc., parent company to 14 Blue Cross plans. Dr. Levinson also operates www.helpingchiropractors.com, a training and consulting company. The opinions expressed in this article are Dr. Levinson’s and do not necessarily represent the viewpoints, ideas or opinions of WellPoint Inc. or any Blue Cross Blue Shield insurance company.