Since you can’t buy insurance for this protection

since you can't buy this insurance

“Dear Doctor:  A recent review of your medical records indicates the lack of documentation to support your billings.  Please remit $200,000 within the next 10 days…”

Similar greetings have been expressed to numerous physicians as health plans continue to find challenging coding and documentation to be lucrative.  Each health plan is required to have a “special investigations unit” sometimes called “fraud and abuse” whose task was to be to see out abusive billing practices, and suspicious billing patterns.  Not unreasonable as there are always a few physicians that have few insurance carriers as a party to fleece.

However, the players have found these special investigation units to be not just looking for bad apples, but revenue sources, expected to generate a solid return on the cost of the department.  The efforts of these departments are expected to produce actual dollars in revenue through recoveries from physicians for past paid claims, and in the process, create a chilling effect on physicians in general, causing many to self-under code to try and stay off the radar.

When such a letter arrives, physicians are often surprised, “I had no warning”.  In reality, physicians must understand that as they bill their coding pattern is being monitored.  And using algorisms that compare each physician’s coding pattern with those of others and with industry norms, quietly and without fanfare, the special investigations unit, usually without their name on the letterhead, sends requests for medical records.  Often offices simply send them, unreviewed, and without even telling the physicians.  After all, the health plan wants them, and your contract says you have to provide.  Its nothing, its routine.  Even if your office were to call and ask why most likely you will not get a straight answer.  The “Unit” is building it case – against you. And when they have the records, and they already have your billing, they have the evidence.  The documentation is either there, the services are appropriate for the diagnoses, or its not.  If not – they send their greetings and their request for an economic recovery from you.

With an investment, you can relieve yourself of fear of these fearsome units.

Every year you should invest in a review of your documentation and its ability to support your billing by a certified procedural coder, one trained on physician coding.  An investment of say $2500 to $5000 should provide funding of a sampling of your records that a good picture of your documentation and billing habits can be made. No, do this little legal maneuver to give yourself an extra bit of protection, ask that your attorney (or any attorney, your bother in law that does real estate even) hire the reviewer under a Kovel letter, which makes the coder’s work protected from discovery.  This means that their finding cannot be discovered in a legal action. Helpful if your records don’t support your billing.

Then let the coder do their work and make recommendations for improvement.  Many times, physicians find that they have been under-billing (remember that chilling effect that payers want to create to suppress your billing?  Its working).  In others when the documentation is not sufficiently supportive, the coder can work with you to structure relatively easy reminders and tools to build the proper documentation to support your billing.  With services proper for the diagnoses, and procedures fully documented you amour proof your billing.

Then you should not be afraid to bill what you do, and if challenged, your records will support your billing, and you should use your coder to help push back on any challenge.

Don’t fall into the trap of under-coding yourself, it’s your income, you earned it, and you should actually bill and collect it.