| Health care fraud comes in many forms and | | | | supplies |
| unfortunately is not limited to any one health care | | | | Documentation: If it is not documented then it did not |
| discipline. Chiropractic is not immune from their | | | | happen; Inadequate documentation to establish need, |
| members engaging in fraudulent activity that violates | | | | support rendered, who provided; Non-health care |
| the laws and rules governing health care. With more | | | | documents in the file; multiple patient files for same |
| than twenty years of experience, including investigating | | | | patient; Notes prepared to support payment - not |
| chiropractic fraud and assisting chiropractors on | | | | health care rendered; prepared only when requested |
| employing compliance programs, I offer the following | | | | by payers; Notes more extensive for liability carriers, |
| bullets to refresh and/or develop fraud-fighters | | | | reports appear the same on all patients; Scheduling |
| (providers, insurers, regulators & law enforcers) | | | | books, sign-in sheets, wand, computer generated |
| insight on chiropractic fraud. | | | | notes, travel cards, forms, checklists, etc. |
| Chiropractic Fraud, A growth industry... | | | | Coding: Follow the money! ICD-9, CPT-4, CMS-1500 |
| Ignorance: Lack of knowledge and/or understanding of | | | | (instructions); Goal is to bill certain amounts per patient |
| the laws and rules that govern health care. | | | | visit; Quick codes - automatically bill; Report all services |
| Benchmark appropriateness of practice conduct | | | | insurance covers (regardless of need); Use codes |
| based on what (they) perceive everyone else is doing. | | | | based on what paid - not what done; External billing |
| Seminars: Increase income has very little to do with | | | | companies |
| improving patient care. May provide information | | | | EXAM RED FLAGS: Free services; no ICD and CPT |
| inconsistent with health care laws and rules. Trust but | | | | link; Patterns; Comprehensive and/or daily exams billed; |
| verify not followed here. Ads in chiropractic periodicals | | | | No initial exam or re-exams billed; Modifier -25; |
| can assist on identifying current and developing | | | | Consultations; Extended visit codes; Multi-discipline |
| chiropractic fraud trends. | | | | practice (MD, DC exams, PT evals) |
| Practice Builders: Instruct on methods and means to | | | | TEST RED FLAGS: Free services; ICD and CPT link; |
| increase practice revenues and patient retention. | | | | Patterns; Extensive on subjective |
| Aggressive marketing; increase services - especially | | | | X-ray reading codes; Tests on visit after exam; |
| tests. How to use the "CA" to build the practice; and | | | | substandard testing devices; Mobile Labs, Multi-discipline |
| may instruct on how to circumvent limitations on | | | | practice (DC x-rays billed under MD) |
| chiropractic. | | | | TREATMENT RED FLAGS: Free services; ICD and |
| Multiple Clinics: (Facilitator) Assists on opening clinics, | | | | CPT link; Patterns; Subluxations only on Medicare; |
| instructs on what to do, how to bill, etc. | | | | Time-based; Modifiers; No CMT billed (Manual |
| (Operator) Own/operate multiple clinics; scripts and | | | | Therapy); Place of service; Multi-discipline practices |
| protocols are the norm; high turnover rate | | | | SUPPLIES/REPORTS RED FLAGS: Free services; |
| Both recruit extensively from Chiropractic Schools. | | | | ICD and CPT link; Patterns; Excessive charges; TENS, |
| Vendors: (Manufacturers) Peddle devices with no | | | | Supplies; Educational supplies/services; Special Reports |
| specific code; provide a number of codes to get paid | | | | Analysis; Multi-discipline practice |
| (Billing Companies) may offer little or no oversight; may | | | | Collection Fraud: Insured's pay more for similar services |
| facilitate improper billings. (Testing) Increase revenues | | | | than cash patients; Accept what insurance pays; forgo |
| and patient retention; objectify the subjective; Mobile | | | | collection of deductibles, co-pays, etc.; Medicare |
| Labs - kickbacks. | | | | beneficiaries often induced and may pay more for |
| Chiropractic Fraud, Types of Fraud | | | | care (CMT) than other patients; Seek compensation |
| Marketing: Goal is to get as many people in the clinic | | | | for non-covered services reported as if covered (in |
| as possible for conversion regardless of actual medical | | | | name of covered provider); Attorney reductions, TOS, |
| need; Telemarketing, mailers, screenings, dinner talks, | | | | Financial hardships, pre-pay; External billing companies |
| scripted presentations, etc; promise "free services" to | | | | typically do not involve themselves with cash patients; |
| induce into clinic; Identify available insurance, or | | | | Forms, checklists, EOB's, payer contracts, carrier |
| willingness to commit to payments - find condition - | | | | manuals, practice acts |
| convert - treat - bill. | | | | Health Care Fraud |
| Services: Not rendered; not medically necessary; not | | | | Services not rendered: Billed exam following promised |
| recognized clinically and/or scientifically; substandard; | | | | free exam; Daily exams; Services not documented; |
| Patients get same services on similar schedule - even | | | | Services of one provider under another provider; CPT |
| when better (phases of care, ROF); Services based | | | | codes not reflective of what performed; Quick-codes; |
| on available insurance or for legal reasons - not need | | | | Multi-discipline practices; mobile labs; manufacturers; |
| (intake forms); Services for conditions not found in | | | | multiple clinics |
| presenting complaints (aggressive marketing) | | | | Substandard/unnecessary services: Free exams and |
| EXAMS: Free exams; Patterns; No exam performed; | | | | services (inducements); Treat conditions not identified in |
| Extensive on subjective injuries; Does not address | | | | presenting complaints; Same services/similar schedule; |
| presenting complaints; Pre-determined (scripts, phases | | | | Protocols/phases of care; Incomplete/inaccurate |
| of care); Inadequate referrals | | | | documentation; Not responsible what not paid by |
| TESTS: Extension of exam, technical/professional; | | | | insurance; Provider services by non-providers; by |
| Free testing; Patterns; Extensive on subjective injuries | | | | patients; Multi-discipline practices; mobile labs; |
| (objectify); No relationship to patient complaints; Results | | | | manufacturers; multiple clinics |
| not used in care and treatment; Use devices not | | | | Misrepresent nature of service provided: Exams |
| recognized | | | | (Comprehensive - Pattern - Daily); Diagnostic testing |
| TREATMENT: Free treatment (massage); Patterns; | | | | not used in care and treatment; Codes based on what |
| No relationship to presenting complaints; Provider | | | | paid, not what done; Upcoding, unbundling; Provider |
| services by non-providers; One-on-one services; | | | | services by non-providers; One-on-one services not |
| Patients direct treatment, treat themselves; Medicare - | | | | one-on-one; Improper use of modifiers; Medicare; |
| CMT only; Non-covered provider (managed care); | | | | Multi-discipline practices, mobile labs, manufacturers, |
| Multi-discipline practices (treating same) | | | | multiple clinics |
| SUPPLIES/REPORTS: Supplement/adjunct to | | | | Misrepresent actual service provider: Provider services |
| treatment; Patterns; Supports, braces, TENS, etc.; | | | | by non-providers; Services self-administered by |
| Provide - Rent - Sell; No relationship to patient | | | | patients; Services by one provider but billed under |
| complaints; Administered at clinic as well as at home | | | | other (covered) provider; Multi-discipline practices; |
| Supplies/materials; Special reports; Educational services | | | | mobile labs; multiple clinics. |