Ticket to a Denial

Hot Topics from the KMC University HelpDesk

Over the past decade, there have been multiple observations within the chiropractic profession that have drawn the attention of the OIG (The Office of Inspector General). In 2016, reports indicated that hundreds of millions of dollars in Medicare payments were made for chiropractic services that did not comply with Medicare requirements. This issue escalated in 2018 when the OIG published a report stating that 89% of chiropractic Medicare claims lacked sufficient documentation for the services ordered by chiropractors. Finally, in 2021, approximately 163,000 chiropractic claims included at least one incorrectly submitted treatment code, resulting in improper payments that did not meet established standards of care.

Unfortunately, lack of anything when it comes to OIG and Medicare is a one-way ticket to a denial. It’s time to free your practice from doubt and get your records in tip-top shape!

Here’s the lowdown on why Medicare typically says “nope” to payments:

  • Unnecessary Services: Billing for medically unnecessary services, even with that AT modifier, is a big red flag. Medicare’s looking for the real deal, not just a workaround.
  • Wrong Codes: Seriously, there are only three valid CMT codes for chiropractic services, yet folks are still messing this up! Your coding needs to match your documentation, plain and simple.
  • Missing Documentation: This is a huge one. A study found that over half of record requests went unanswered. If they ask for your notes and you don’t send them, it’s basically like saying you never had any to begin with!
  • Insufficient Documentation: Even if you send something, if it doesn’t clearly show medical necessity and meet their standards, it’s not going to fly.

Listen, these aren’t new issues. OIG has been flagging these problems for years, but the pressure is on CMS to audit, review, and recover any overpaid funds. This means a more aggressive approach toward chiropractic practices, and you’ll definitely feel the squeeze.

It’s an old saying, but it’s true:

“Where Medicare goes, the world will follow.”

Medicare’s rules often become the blueprint for other insurance companies. So, if Medicare is cracking down on fraud and waste, you can bet other third-party payers will too. Get ready for more audits and payment recoupments across the board.

So, what’s the takeaway?

Your documentation has to match your claims and meet all those pesky payer guidelines. And honestly, a lack of good documentation (or no documentation at all!) is a huge risk, but it’s also super easy to fix.

Now’s the perfect time to give your documentation a good once-over. Make sure your paperwork is accurate and up-to-date. Take control and protect your practice by revamping your note-taking to be efficient and feel the freedom that comes with knowing you are compliant!

Need help getting started?

Reach out to our HelpDesk anytime for expert support and training.