How to Prepare for and Manage Payer Audits

How to Prepare for and Manage Payer Audits

There isn’t a chiropractor alive who doesn’t shudder at the thought of being audited. The feeling that every payment request is being scrutinized for the slightest error is a huge pressure, but it can be lessened by proactively prepping and managing the process yourself.

The more thorough you are about in-house documentation, the less chance that auditors will call you out for a refund. Put these best practices in place as part of your everyday operations, and you’ll feel much less apprehensive about justifying expenses.


Set a Baseline

Starting from the bottom up helps you discover if your practice is getting the basics right. Exposed weaknesses will help you create a road map on how to be better prepped for audits. Begin with coding: products, supplies, and services all require the proper HCPCS codes. These are updated annually, so it’s vital your team stays up to date. Don’t forget that there were other big changes in coding that came into play this year.

After accuracy comes clarity. Does everyone in your practice have neat handwriting? Scrawled dates, codes, and signatures are very hard for auditors to read, which can lead them to question your records. Make everything you write is legible beyond doubt. Better yet, record everything digitally on chiropractic software and electronic health records. Your data will be crystal clear, and it can be backed up in the cloud or on removable devices to prevent loss.

Next, make sure every service you provide to patients is necessary as per the payer’s guidelines. These guidelines may vary from payer to payer based on their individual medical policies. Diagnoses must match procedures in every instance, and treatment must only last as long as it is considered medically necessary, again, often according to the payers’ guidelines. Every patient should have a care plan drawn up after your consult and examination that outlines your plan of care, along with timelines. Progress will be organic, of course, but if a payer audit is triggered, you’ll be able to prove that you had purpose, direction, and an end goal, and weren’t just aimlessly prolonging treatment.

Manage Audits Through Confident Challenge

An eye-opening article by The Strategic Chiropractor reveals some very lax practices on the part of auditors. From note requests and vague descriptions to bundling, extrapolated refunds, and shaky credentials, there’s a lot for practices to challenge when an audit letter arrives. Managing an audit can involve contesting it in court, an unpleasant and expensive scenario that may sway some chiropractors into accepting they’re “wrong” to avoid further hassle. However, if you’ve implemented a compliance plan that self-monitors practice procedures, clearly defines policy and performance expectations, and takes action against internal violations, then you’re in a stronger position to challenge payer audits. The good news is, when you have your records in order, you have a great chance of winning.

About Author

Ray Foxworth, DC, FICC, MCS-P

Dr. Ray Foxworth, DC, FICC, is the founder and CEO of ChiroHealthUSA. For over 35 years he worked "in the trenches" facing challenges with billing, coding, documentation and compliance in his practice. He is a former Medical Compliance Specialist and currently serves as chairman of The Chiropractic Summit, at-large board member of the Chiropractic Future Strategic Plan, board member of the Cleveland College Foundations, and excutive board member of the Foundation for Chiropractic Progress. He is the former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and past chairman of the Mississippi Department of Health.Go to to register today.

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