tracelogoRB Providing support and step-by-step guidance throughout the entire audit


Fraud and Abuse 

Fraud and abuse are widespread problems and very costly to America's health care system. Although no precise dollar amount can be determined, some authorities contend that insurance fraud constitutes a $100-billion-a-year problem.


Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, and/or are unfairly priced. Abuse, while similar to fraud, occurs when it is not possible to establish that the abusive acts were done with the intent to deceive.


Post-Payment Audits 

Government and private payors often utilize post-payment audits of health care records to identify fraud and abuse. Unfortunately, audits of chiropractic health care records performed over the last 10 years, by both public and private payors, has revealed improper coding practices, poor documentation, billing for medically unnecessary services, billing for non-covered services and waiving co-payments. These audits can result in significant repayment demands from payors. If you undergo a post-payment audit, you bear the burden of exonerating yourself. Auditors assume you should have known certain practices were abusive and/or perhaps fraudulent.


Excellent clinical documentation is essential in establishing medical necessity for treatment billed during a file audit. As important as that is, it is equally imperative to understand some of the triggers for those audits to become more proactive in preventing an audit or review in the first place.


Common Audit Triggers include:

  • Complaints by patients/employees.


  • Advertising for free or reduced covered services.


  • Provider website content.


  • Unusual practice patterns with respect to utilization, including:

  1. Billing for non-covered services.


  2. High average number of visits per patient.


  3. High average number of therapies per patient.


  4. High average cost per visit.


  5. High average cost per patient.


  6. Unusual CMT code usage.


  7. Unusual E/M code usage.


  8. Long term use of passive therapies.


 Common Audit Findings

  • Illegible documentation (health care record cannot support services billed).


  • Lack of medical necessity for services billed.


  • Services inconsistent with corporate medical policies.


  • Waiving or reducing co-pays.


  • Billing for non-covered services.


  • Up coding.


  • Treatment billed not substantiated by treatment plan.


  • Insufficient documentation to support x-rays billed.


  • Inadequate documentation to support level of CMT or E/M services.



What to do if you are notified of a post-payment audit of your health care records: 

HNS hopes that you never experience a post-payment audit of your health care records. But if you do, we are here to help. Please contact us immediately if you are notified that your records have been requested for an audit and we will provide you with expert step-by-step guidance and support.


HNS provides assistance throughout the entire post-payment audit process. We will promptly perform an initial review of the health care records requested by the payor to assist in identifying potential problem areas before you release your records to the payor. We will review your utilization patterns for services filed to that payor and provide you with utilization data relevant to the audit. We can also put you in touch with other health care professionals who have been audited and have survived the audit process!


HNS will work closely with you and the payor throughout the audit process in an effort to assure a fair determination is made by the payor, so if you are notified of an audit, contact HNS immediately and we will provide support and assistance.