PATIENT DOCUMENTATION
The Collection Coach has spent thousands of hours researching, planning, and developing a documentation system to
simplify your patient workflow and maximize your profitability. Our forms and processes have withstood multiple
insurance audits—rest assured, if you have to go through an insurance audit, you will have the right tools.
Medicare and insurance documentation are confusing. That’s why The Collection Coach’s SMART
Documentation System organizes patient information into a simple, intuitive documentation process while promoting
compliant protocols in your office. The protocols are in place to make sure that you meet those requirements on
every patient — not just Medicare.
In these tough economic times when many clinics are getting out of insurance altogether and going to “cash”
practices, The Collection Coach clinics are flourishing and growing. There are four main ways to grow your
practice:
- See more patients (Get more new patients and deliver more chiropractic adjustments)
- Increase services (Chiropractic adjustments + therapies + rehab...)
- Diversify your product line (sell vitamins, T.E.N.S., belts, braces, orthotics...)
- Documentation
If you do the first three steps and do not document correctly, you may find yourself facing a “post payment
review” where you may have to give back literally hundreds of thousands of dollars to an insurance company
or Medicare. Once you learn how to document your services and code them correctly, your practice will
automatically grow because your certainty will grow — these two things are intertwined. In our
experience, documenting correctly can solve nearly all of your payment problems.
COMPLIANCE
Compliance with the Office of Inspector General (OIG) is mandatory. As part of an office’s “compliance
program”, the Office of Inspector General (the governmental agency that oversees CMS or Medicare) requests
that each office conduct periodic SELF-AUDITS.
The Collection Coach recommends that these self-audits are done at least twice a year to ensure proper
documentation and coding compliance. While this sounds like a lot of work, it is better to be proactive than to
wait for the OIG or an insurance company to come knocking on your door. Why? Because the OIG reports that any
provider that can show a compliance program in place will be dealt with more leniently. That means even if an
audit or your notes reveals that you are lacking the appropriate documentation on some dates of service, the
penalties and fines will not be as severe.
THE BENEFIT of using the Collection Coach’s SMART Documentation System is that you will be doing a “self-audit”
on each patient, every time you use the forms. Plus, the SMART Documentation System will always guide you to the
most appropriate CPT code to bill.
Gone are the days of guessing about a billing code for example:
“I spent a lot of time with the patient, so I billed a high level exam (99204 or
99205)”
“That is the code I always use (99202 or 99203)”
“I always bill a 98940 (1-2 region adjustment) because I want to fly under the radar”
If one of the above quotes sounds like something you would say, you are throwing money away! That is right, in
most practices this amount is between 50,000 and 80,0000 dollars per year! You could be leaving money on the table
that is rightfully yours. Whenever you provide treatment which manages or stabilizes a patient’s condition,
insurance companies, third party payers, and Medicare are required to pay you — but you have to know how to
properly document the treatment in the patient’s medical notes.
We give you the right tools to protect your practice from an insurance audit.
Call us today and learn how we can help your practice earn more and KEEP more.
