Recently, many chiropractors throughout the nation received their Comparative Billing Report (CBR).  In an attempt to educate top utilization providers, the Zone Program Integrity Contractors provided a CBR.  Whether you received a CBR or not, you need to take notice of the findings of the report.

The Centers for Medicare and Medicaid Services (CMS) has added a new contractor in its army of health care auditors.  The Zone Program Integrity Contractor (ZPIC) is the latest approach by CMS to audit and enforce its program guidelines.  Prior to the formation of the ZPICS, there were different entities such as the Program Safeguard Contractors (PSC), Medicare drug integrity contractors (MEDICs) and the Recovery Audit Contractors (RAC).  There was no uniformity in jurisdiction for each of these entities, therefore one entity may be overseeing a portion of Part A providers (hospitals) and another may be overseeing another portion of Part B (physician’s offices) in the same state.

To make the system more efficient, CMS has given jurisdiction to the ZPICs to oversee all Medicare claims for their appointed zones of the state.  Eventually, ZPICs will be entrusted in ensuring the integrity of all portions of Medicare.  This will include Part A, Part B, Part C and Part D Medicare.

In respect to the Comparative Billing Report, this report was sent to the top 5,000 utilizers and providers to the Medicare program.  As such, if you received a CBR, you are one of the top 5,000 chiropractors seeing Medicare patients.  Good for your practice, but not so good for looming audits.  ZPIC has used information from the CMS computer profiles to not only see who are the top providers, but also where you are skewed compared to your colleagues.

It is to your benefit to study your profile and compare yourself to others nationally, but especially in your state.  If you are too high in one area, then you may be singled out for a future audit.  When I recently called the ZPICs, I was informed that they are not using this information for audits “at this time.”  The person on the telephone was emphatic about the “this time.”  One can extrapolate that a statistically significant deviation in the numbers of 98940, 98941 and 98942 claims may be an indication of improper usage.  As such, the question of medical necessity will be a trigger for a possible audit.

Keep in mind that the CBR is for educational purposes.  I wonder if you have been educated that there is a statistical difference between you and your peers and you continue to practice in the same manner, might this indicate an intentional over utilization.  This in itself may be indicative or at least construed as fraud.

For those providers that have not received a CBR, you may still be vulnerable in your practice for an audit.  As such, it is recommended that you request a Physician Profile on yourself through the Freedom of information act.

As a Compliance consultant, I have personally seen a rise in the number of Medicare and Blue Cross audits in the last year.  Whether you are a participating provider or non-participating provider does not alter the chances of being audited.  Medicare clearly stated that the fact that you are par or non-par does not alter the likelihood of an audit.

To prevent an unforeseen audit and eventual reimbursement of funds to Medicare or another carrier, it is recommended that you become proactive in your approach to documentation, coding and compliance.  This can be accomplished through internal audits and education.

The most accurate way to assess your entire practice is for an audit or review at your office.  The Office of Inspector general has stated that a proper compliance audit and manual will not only uncover deficiencies in your practice, but will also is used as a mitigating factor in the case of fines and/or jail time.  Another alternative is to have a competent certified compliance specialist audit your charts for documentation, billing and coding checked for accuracy and compliance.

Many are frustrated by the level of audits conducted by carriers, but accountability, accuracy and efficiency are key to a practice with decreased stress.  Having a cash practice will not preclude you from audits.  Don’t forget that your documentation is also important to thwart any type of malpractice or negligence litigation.

Many opportunities are being offered to our profession by the Illinois Chiropractic Society.  For a listing of upcoming Medicare, coding and compliance classes, see our website at www.ILChiro.org

Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant.  For further information on compliance audits or record reviews, please contact Dr. Fucinari at Doc@Askmario.com  Classes are now forming to become a Certified Compliance Specialist (MCS-P).  See www.AskMario.com for details.