Chiropractic Billing Red Flags: What Is External Data Mining?

For chiropractors, mastering the art of insurance-based billing and compliance is not just a necessity — it's a strategic asset. Chiropractors may face more scrutiny of their billing practices and an increase in denials if their billing and coding procedures are inaccurate or noncompliant.

Accuracy and compliance are more important now than ever.

Some healthcare insurance companies are using external data mining to detect billing inaccuracies and prevent insurance fraud. This practice involves analyzing data to identify irregularities and ensure accurate and ethical billing.

From mastering accurate coding to maintaining consistent documentation and conducting regular self-audits, we'll guide you through the steps to fortify your practice against negative flags and maintain a harmonious relationship with insurance providers.

What Is External Data Mining?

External data mining is a process insurance companies use to access and analyze healthcare data. They typically obtain this data through agreements with healthcare providers, electronic health record (EHR) systems, and claims databases.

They use advanced algorithms and computer programs to scrutinize patient records, treatment histories, and billing information. This helps them look more closely at a practice’s insurance and billing procedures and spot chiropractic billing fraud.

Insurers look for common chiropractic billing mistakes such as:

• Claim outliers. These instances are anomalies within the data, such as an unusually high frequency of treatments for a common condition. This may raise concerns about possible over-treatment or billing inaccuracies.
• Data trends. Insurance companies conduct this analysis to identify evolving trends, such as a surge in a particular treatment. This could signify a shift in how healthcare is provided or highlight coding errors.
• Patterns in billing and treatment. This includes identifying recurring practices that differ from the usual, such as frequent billing for higher-cost treatments, which may indicate potential upcoding or unnecessary procedures.

As a chiropractor, staying informed about how insurers use your data is important. This knowledge allows you to implement ethical billing strategies, reduce the risk of audits, and promote transparency in your dealings with insurers.

Common Flags for Chiropractors

When reviewing your practice’s data, an insurance company may look for specific chiropractic billing error red flags, including:

• Unusual billing frequencies. When a chiropractor consistently bills significantly more or less frequently than their peers for specific procedures, a practice known as chiropractic upcoding, it can arouse suspicion. For example, billing for daily sessions of the same treatment may lead to scrutiny from insurance companies or auditors.
• High claim costs. Submitting claims with costs significantly higher than industry standards for similar services, like routine adjustments, could draw attention.
• Frequent use of modifier codes. Frequent and excessive use of modifier codes, which are used to denote special billing circumstances, may indicate inconsistent coding practices. For instance, the overuse of the 59 modifier could lead to further investigation.
• Inconsistent documentation. Differences between the treatment recorded in patient records and the services billed can raise concerns with health insurers. Chiropractors should ensure their billing matches the documented care provided to prevent disparities.
• Overuse of ancillary services. An insurance company might mark a practice for review if a chiropractor frequently invoices for ancillary services like X-rays or diagnostic tests without evident medical necessity. Including appropriate justification for these extra services can help prevent potential problems.

If an insurance provider identifies these warning signs through data analysis, it can impact your chiropractic practice. When insurance companies spot unusual billing trends, they may launch audits or investigations, which can demand your time and resources.Failure to address these issues appropriately can result in penalties and legal issues, harm your practice’s reputation, and strain your relationship with insurers.

How Chiropractors Can Avoid Negative Flags

To prevent negative flags identified through data mining, your practice should implement documentation and billing procedures that reduce errors and inconsistencies.

Accurate Coding

To avoid negative billing flags, prioritize accurate coding by selecting the appropriate code corresponding to the service rendered.Avoid upcoding or downcoding, as these practices can result in suspension and raise concerns with insurance providers. Upcoding involves billing for a higher-level service than what was provided, while downcoding involves billing for a lower-level service.Both practices can lead to incorrect reimbursement and potential fraud, which insurance providers take seriously.To protect your practice’s integrity and streamline billing, consider using chiropractic billing software that integrates with your EHR. This software automates code assignment based on documented treatments and seamlessly integrates them into the claims process, reducing errors and ensuring accuracy.

Consistent Documentation

Consistent documentation is essential for billing accuracy. Ensure that patient records thoroughly and accurately reflect the care provided during each session. This includes a detailed account of the treatment, its duration, and any additional services rendered.Pre-formatted templates for SOAP notes can help with fast, compliant documentation. These allow you to choose from formulated procedure descriptions and menus so you don’t risk incomplete or illegible notes. This provides a clear history of patient care, minimizing the risk of discrepancies or negative flags by insurers.

Regular Self-Audits

Engaging in routine self-audits is a proactive step to maintain accurate billing practices. Allocate dedicated time for these self-audits at consistent intervals. During these assessments, ensure that the services delivered match patient records, that the billed amounts align with the services provided, and that all CPT codes are correctly applied.During these self-audits, be vigilant in identifying any inconsistencies or discrepancies. If you come across any discrepancies, take prompt corrective action. This may involve rectifying billing entries, revising documentation, or seeking chiro billing compliance tips from industry experts.

Stay Informed and Proactive

The best way to protect your practice against insurance issues from insurance data mining is to educate yourself and your staff on the latest coding, treatment, and chiropractic billing guidelines. This allows you to identify issues and implement the appropriate procedures for resolution.To stay up to date with the latest information, consider the following:

• Subscribe to industry newsletters. Stay informed by subscribing to newsletters from reputable sources in the healthcare and chiropractic industry, like the American Chiropractic Association (ACA) and CMS. These may provide updates on coding changes, billing guidelines, and industry trends.
• Attend workshops. Participate in workshops or industry webinars focused on coding, treatment, and billing in chiropractic care. You can find workshops and conference events through the ACA’s events site or Parker Seminars.
• Consult with healthcare attorneys. Seek legal advice from healthcare attorneys who specialize in chiropractic care. They can guide compliance, billing regulations, and potential legal issues.
• Speak with a billing specialist. Collaborate with a billing specialist who has expertise in chiropractic billing. They can offer specific advice on billing codes, claim submissions, and handling insurance-related challenges.
• Use a cloud-based EHR. Use ChiroTouch, a cloud-based EHR system that offers real-time updates and compliance features such as auto-coding, streamlined billing, and soap macros. ChiroTouch can help you remain current with coding and billing changes, ensuring that your practice’s documentation aligns with the latest guidelines.

Eliminate Chiropractic Billing Red Flags With ChiroTouch

ChiroTouch is a leading software solution tailored specifically for chiropractic practices and designed by chiropractic professionals. Our EHR and practice management software is trusted by over 36,000 users, who benefit from innovative, updated features like automated billing and insurance, preformatted SOAP notes, and integrated patient records.

Discover how ChiroTouch can help you eliminate billing red flags, minimize denials, and increase revenue.