In Illinois, a psychiatrist was sentenced to 23 months in prison over Medicaid bills that added up to $75.25. In California, one doctor served five years in prison over $65,000 in disputed Medicare bills. Something has happened during the past decade in health care that has driven audit rates through the roof. Average judgments are also shockingly high when compared to years past, leaving everyone who cares to ask wondering - emphatically - why.
In its January 2007 issue, Today's Chiropractic examines an unprecedented growth of post-payment audits by insurance companies. Such audit growth is apparent in terms of both audit frequency and judgments.
As any social scientist will tell you, the suggestion that the rise in audit rates is indicative of a concerted increase in fraudulent activity among providers is absurd. It is more likely that the payers have started doing something differently. Indeed, the "scene" in the title of this section alludes to a new payer strategy adopted a few years ago: large-scale claims monitoring, fine-tuned provider targeting, and merciless audit.
A study was conducted by Brian Capra, Doctor of Chiropractic and an owner of chiropractic clinic, Yuval Lirov, PhD, patent inventor in Artificial Intelligence and Computer Security and book author of "Mission Critical Systems Management," and Jeffrey Randolph, Esq., Legal Counsel of Association of New Jersey Chiropractors.
The surge in audits is motivated by a combination of three factors, namely, continued pressure to turn higher profit by insurance companies, inability to raise insurance premiums, and timely payment laws. Premium wars preclude them from raising rates, and recently enacted timely payment laws limit how long they can withhold repayment to earn interest as they had in the past. To meet profit expectations and still play within the new rules, insurers have decided to go after the reimbursements after they are paid.
The means to identify the easiest and most profitable audit targets is facilitated by a Big Brother system, built automatically during claims processing. As providers submit claims to be paid, insurers simply add each claim to their growing database. The system automatically pinpoints providers that are doing something differently from the pack.
While the motive is money and the means is a gargantuan statistical database, every provider is an opportunity. To manage audit risk, providers need a Big Brother system of our own. Such a system, modeled on the insurers' own, stores claims data and generates reports for the benefit of participating providers.
"With teamwork, discipline, and state-of-the-art infrastructure, chiropractors unite and transform disparate stand-alone billing operations from the many into the mighty and become a powerful community of profitable and compliant managers focused on patient care and practice growth," says Dr. Brian Capra.
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