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

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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 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
dont 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.
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Red Flags under Chiropractic Medical Billing you
need to Watch Out For?
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 doesnt fit into the
carefully selected categories, they may be
flagged for possible fraud.
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Red Flags under Chiropractic Medical Billing you
need to Watch Out For?

• Red Flags for Chiropractic Billing
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• 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 insurers
  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 arent 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.

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