The Elephant in the Middle of Our Professional Living Room

The "elephant" I'm talking about is noncompliant documentation, and in a nutshell, for your "notes" to be compliant, they must all support all three of the following:

• The medical necessity of your care, per the carrier's guidelines
• The therapeutic benefit of every service you provide, document and bill must be appropriately documented and substantiated, per the carrier's guidelines
• Meet the documentation parameters of the carrier – you guessed it, per the carrier's guidelines

Here are a couple of fun statistics to ponder: 1) 37-50 percent of all chiropractors who bill insurance have noncompliant documentation and are therefore at risk of failing a documentation audit;* and 2) Most DCs have not read the carrier documentation guidelines for carriers with whom they participate.

Why This Matters

If documentation for services you have already been paid for is requested by a carrier and reviewed, and that documentation is found to not meet the carrier's criteria for demonstrating medical necessity and supporting the services billed, the carrier can and will ask for that money back.

Insurance carriers know documentation compliance is a huge problem for our profession, and they are taking advantage of it. We are the "low-hanging fruit" and they are aggressively auditing DCs as a revenue stream.

Sound scary? It should! Myself, along with dozens of my colleagues who were audited by Anthem Blue Cross Blue Shield in Virginia in 2018, collectively lost millions of dollars in recoupments, denied claims and lost practices. Prepayment review means services going-forward are submitted on paper claim forms along with all documentation, each DOS is reviewed by a human, and payment is dependent on whether each DOS meets all carrier documentation criteria, usually for a year.

A Problem of Implementation

I have interviewed, surveyed and done onsite visits with hundreds of DCs over the past few years, and I have found:

• Most DCs have attended one (usually more) documentation workshop in the past 1-3 years (from my surveys of DCs in Virginia), and yet many still have noncompliant documentation.
• Many DCs who have noncompliant documentation are using ONC-certified EHR software.

Documentation workshops have been taught the same way for more than 10 years, yet this problem has persisted. I contest that DCs are not just lazy, in denial and/or won't sit down and fix their notes. The problem is bigger to solve than going to one more "information dump" and sending the doc home and saying, "OK, now go fix it." The problem is not a lack of information; it is a lack of implementation.

Creating compliant documentation also means changing ingrained office habits, policies and procedures. It means updating EHR and its effective utilization. It means staff training or retraining. It even means patient training ("But I've always come once a month!"). Everyone in the office needs to understand compliance and an implementation strategy must be created.

Risk Alerts for Noncompliance

Based upon my personal surveys and experience consulting and doing onsite visits with my colleagues:

• The longer a provider has been using EHR software, the greater risk they face of being noncompliant (because they are using old macros).
• DCs who use "empty template" EHR software (for example a new, popular "app" EHR) in which providers use "blank areas" to document their visit encounters have a high likelihood of having noncompliant documentation.
• DCs using documentation templates/macros shared/uploaded by colleagues in a "library" maintained by EHR companies. This was very common when EHR companies launched (remember that, guys?), and many DCs are still using those old, noncompliant functions.
• EHR software companies frequently market their product and its "customization" capacity, when in reality the more a user customizes their software to "say what they want their notes to say," the more likely their documentation is going to be noncompliant (because it's not what the carrier wants to see).
• DCs who are greatly concerned with communicating their technique-specific information (e.g., adjustment listings, device used) have a higher likelihood of noncompliance.

Five Practical Takeaways

These apply even if you think your notes are "pretty good" (just kidding, they're probably not):

1. Change your mindset now: If you are thinking that this is ridiculous, dumb, unfair or <insert your favorite adjective(s) here>, protesting your disagreement by refusing to abide by the guidelines is an ill-advised strategy of dissent. Fix your notes; then work for change through other appropriate avenues.

2. Review all carrier guidelines: Print out guidelines for all participating plans; then sit down in a staff meeting and review them aloud, together.

3. Identify deficiencies by comparing the guidelines to a printed typical patient DOS; not just what the DC puts in the notes, but also: Is your office weak in getting patients to adhere to care plans? Are other providers/therapists properly documenting and electronically signing off?

4. Triage an "action plan": Chances are you and your staff have identified multiple areas of deficiency. My surveys have shown most DCs are missing goals, care plans, functional data, statements of therapeutic necessity of each service performed and billed, just for starters. Make a list. Who plays a part in each element,? Start checking things off.

5.For the DC:

• Make sure you've downloaded and are correctly using current EHR macros.
• If you have SALTed-over documentation text from "your old way of documenting," take the time to delete unnecessary or superfluous content.
• Don't rely on what anyone else puts in the documentation to substantiate your care. This includes associates, therapists and even patients who put might be putting in their own subjective information. We all have patients who are forgetful from visit to visit, or who don't take the task seriously. But if a carrier asks for money back, you're the one who is going to have to pay it back.

*CMS/Medicare 2019 Medicare Fee-for-Service Supplemental Improper Payment Data show 37 percent of DCs have noncompliant documentation for submitted services, which for Medicare is only the adjustment code. Expanded to private insurance carriers that cover therapeutic procedures, I have personally found that the documentation noncompliance rate for this expanded range of services is at least 50 percent.