Medicare Audits: What YOU Need to Know

Medicare Audits: What YOU Need to Know

Medical Benefits Claim FormMedicare/CMS has been sending audit letters to many chiropractors across the country. I have had the opportunity to review these letters and speak to many of the doctors that have received them. Below is a list of frequently asked questions and my responses based on the information that I have obtained:

Why is Medicare doing this audit?
This audit relates to a 2015 Office of Inspector General (OIG) report that stated $76 million for chiropractic services were questionable and another $21 million was improperly paid due to a lack of documenting the proper primary diagnosis. There have been other OIG reports that reveal high rates of improper payments for chiropractic services.

Who is StrategicHealthSolutions, LLC (Strategic)?
Strategic is a Supplemental Medical Review Contractor (SMRC) chosen by CMS to identify possible improperly paid claims.

Why was I chosen for this audit?
This audit appears to be based on random selection, rather than a targeted review based on aberrant billing.

Do I have to send in the information?
Yes, you must submit the requested information. If the information is not submitted, it can be interpreted as a 100% error rate and Medicare can initiate an overpayment recoupment for these undocumented services.

Do my patients need to sign an authorization to release records? If I provide Medicare with my patient notes, isn’t that a HIPAA violation?
No, you do not need to obtain patient authorizations. Releasing the information to CMS is not a HIPAA violation.

Can I charge Medicare for making copies of patient records?
No, CMS states that they are not authorized to reimburse providers for the cost of copying records or postage.

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I do not think I’ll have enough time to gather all the records, can I ask for an extension?
Yes, extensions are typically granted. You can call the toll free number provided in the letter and ask for an extension. Asking for an extra 2-3 weeks to submit the information is not an unusual request.

The top of the letter says “Attention: Compliance” – does this mean I should have a compliance plan in place?
According to the Affordable Care Act, providers that treat Medicare patients are required have a compliance manual with written office policies and procedures, train staff members on policies and procedures and keep a log of all staff trainings.

The letter asks for a lot of information, do I need to send them everything?
The letter requests many items to submit. I will go through each one:

  1. Copy of claim bill: I’m not sure why they need a copy of the claim since they have received it already. Find the 1500 form with the dates of service (DOS) requested and submit.
  1. Submit records for all dates of service on the claim: Take a look at the claim that was submitted with the (DOS) requested. Is there more than one DOS on the claim? If yes, you may have to submit the notes for all DOS on that claim. Each set of patient notes should be evaluated on a case-by-case basis to determine what information should be submitted.
  1. Initial and subsequent visits: Look at the date in Box 14 – you may have to submit the notes for all DOS subsequent to the date in Box 14 through the DOS requested. It is not known if they are looking for all subsequent DOS from the date in Box 14 or just the DOS on the claim with the DOS in question.
  1. Progress notes including relevant history: Provide any exams, re-exams that can help support medical necessity for the DOS requested.
  1. Treatment record including the plan or care: The plan of care should include the chief complaint, description of present condition, P.A.R.T. exam, subluxation as the primary diagnosis, frequency/duration of care, goals to be achieved and the objective measures that are used to evaluate the effectiveness of chiropractic care.
  1. Results of pertinent diagnostic tests or procedures: Include any diagnostic test results with your submission. X-rays that show osteoarthritis, MRIs that show herniated discs, CT scans that show stenosis should be submitted.
  1. Ensure the medical records submitted support the service is Active Treatment: The chiropractic Medicare guidelines provide details on active treatment. When submitting claims for reimbursement active treatment is designated by the AT modifier. Claims submitted without the AT modifier will be automatically rejected.
  1. Signature of professional providing service: Every note must be signed and make sure to include your credentials (e.g., DC). The note can be hand signed or if you have certified EHR software, an electronic signature is accepted.
  1. Copies of any patient notices (e.g., ABN form): If you provided chiropractic spinal maintenance care, you should have an ABN form signed and on file available for review.
  1. Any abbreviation keys or acronyms used: If you use unusual/non-standard abbreviations, you must submit a key describing your abbreviations.
  1. Any other documentation: Submit as much information as possible that will help support the medical necessity for the chiropractic services rendered according to the Medicare guidelines.

Can I make changes to my notes once they’ve been entered into the record?
No, however you can put together a treatment summary. This will help explain your treatment approach, clarify any vagueness and point out the most important parts of your documentation to help support medical necessity.

What is going to happen after I submit my notes?
When the review is complete, you will receive a letter of determination. The results letter will stipulate if any underpayment(s) or overpayment(s) were identified. In addition, you may be subject to extrapolation.

What financial impact can this have on me?
If CMS/Strategic finds an error rate of 20% for example, they can apply it to all Medicare payments and request a refund.

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