All insurance payers are obligated to perform routine reviews of claims submitted by providers who operate under their plans. In recent years these claims examinations have gotten more rigorous, with antifraud initiatives being pushed by private health plans and those operating under the umbrella of CMS. The prevalence of insurance fraud has created a hypervigilant 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. The healthcare industry loses billions of dollars annually at the hands of fraud, whether it be intentional or driven by ignorance.

Chiropractic billing fraud in particular has presented itself as a growing issue within the industry. Chiropractors operate differently than providers in other specialties, with highly specific care being delivered to patients. As a result of this specificity, there are a number of factors that could flag a chiropractic practice for a clinical documentation and claims review. Insurers collect physician and provider profiles, an accumulation of data that sets a precedent and signals insurers to any variation from a typical billing pattern. These profiles are put together in such a manner that if a practice doesn’t fit into the carefully selected categories, they may be flagged for possible fraud.

Red Flags for Chiropractic Billing

  • Routinely practicing outside of the common geographical region for similar providers
  • Performing tests that aren’t commonly performed
  • Performing tests that are not identified by CPT codes
  • Using complex CPT codes to describe otherwise routine care
  • Failure to demonstrate medical necessity
  • Using “canned” diagnoses on patients
  • Identical care plans and procedures for patients with varying needs and diagnoses
  • Downcoding, which can still grab an insurer’s attention because it disrupts the expected billing distribution pattern
  • Inordinately lengthy treatment for conditions

Medicare, for example, is looking for providers to bill a certain amount of CPT codes for procedures such as 98940, 98942 (which 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.

The good news is that there is a way around raising those red flags. Educating your billing and administrative staff on correct CPT codes and procedures is the first step. Following the rules and requirements established not only by private health plans, but by CMS, will ensure that the audit process goes smoothly for your practice. Stay current, stay updated, and always confirm that your diagnosis and CPT codes are correct and easily substantiated for each patient, and for each visit.