Five Signs Your Practice May Have Legal Troubles

In today's climate of insurance omnipresence, the chiropractic profession is struggling to maintain its standing as a relevant part of mainstream medical care. The forces of evil, in the form of restricted access to managed health care programs, discriminatory payment practices and unitization-review reductions by managed care and liability insurance carriers, reduced participation under Medicare and state Medicaid programs, increased regulatory oversight by state and federal agencies, and the overall decline in the number of cash patients due to deteriorating economic conditions, are coming together as a "perfect storm" to impose obstacles and hardships on chiropractic practitioners.

Almost 40 percent of all chiropractic practices fail within the first five years of practice. Why? Because while chiropractors receive excellent training in the clinical side of practicing chiropractic during their chiropractic education, they receive virtually no practical training in the legal and business elements required to successfully operate a chiropractic practice.

Bad Habits and Shortcuts

As a result of this lack of preparation, many doctors eventually fall into the type of bad habits that can ruin a successful chiropractic practice. It is imperative that doctors avoid the pitfalls and problem areas that can reduce a thriving practice to one that struggles on a daily basis to make ends meet. Here are five potential signs your practice may be in legal jeopardy and how to avoid them.

1. You Aren't Getting Paid for Your Services

I'm talking about liability insurance carriers who repeatedly reduce your bills through peer reviews on the grounds that your serv-ices are not medically necessary; or managed care companies that routinely deny payment of the services you provide.

Repeated reductions or denials of payment are a sure sign that, in the eyes of the insurer, you are (1) over-treating; (2) improperly coding your services (E&M up-coding, incorrect use of therapy codes, etc.); (3) not adequately documenting the services you provide; or (4) any combination thereof.

Any of the above indicators should be taken seriously enough for you to do a thorough evaluation and audit of your business practices and, preferably, implement a compliance program designed to identify and correct these problems immediately.

2. Insurers Are Making Postpayment Reimbursement Claims

The economy is affecting more than just you and your practice. The insurance industry is feeling the effects as well. As a result, insurers have initiated an aggressive campaign to recoup payments made to doctors when they (the insurance company) deems the doctor to have engaged in one or more of the above-identified areas of (mis)conduct.

Moreover, each of the above acts could be deemed to constitute fraudulent misconduct on the part of the doctor - which could result in a referral for criminal prosecution or at a minimum, lead to civil litigation or termination of your managed care relation-ships.

Postpayment reimbursement claims by insurers can potentially reach the hundreds of thousands of dollars range. Liabilities of this type will almost assuredly damage a successful practice beyond repair, and any referral for criminal prosecution can and likely will result in a serious licensure sanction by the doctor's state licensing board.

3. Your Bills Are Routinely Denied, Requiring Patients to Pursue Legal Action to Recover Their Claims

In this day and age, most judges and jurors are biased against litigants asserting personal-injury claims based upon soft-tissue injuries. It's unfortunate, but it's true and it's not good news for you. Accordingly, liability insurance carriers are repeatedly refusing to pay for the bulk of services you have provided and your patients are required to resort to the courts as a means of settling their claims. In short, you are not likely going to get paid for the services you provided.

If this is occurring on a regular basis, something is obviously wrong with the internal way you are conducting your practice. Your "problem(s)" is/are most likely tied to one of the three problem areas identified in #1 above [see page 15]. Immediate correc-tive action, in the form of a compliance audit of your coding and documentation practices, or a legal audit of the type of marketing and referral relationships you utilize, is in order.