Ever feel like you are playing a game where the rules keep changing? That’s kind of how chiropractic billing can feel.
You help people feel better, but getting paid for it can be tricky. Little mistakes in your billing are like sneaky saboteurs, quietly stealing your hard-earned money.
These mistakes are called “red flags.” Spotting them early can save you a lot of headaches and help your practice thrive.
Think of it like this, you are a detective looking for clues. These red flags are the clues that tell you something is not right with your billing. Ignoring them is like a detective missing a key piece of evidence. It can lead to denied payments, audits, and a lot of stress.
This is your guide to finding these 11 important red flags in chiropractic billing. Knowing what to look for will help you get paid correctly and keep your practice running smoothly.
Let’s become billing detectives together.
Chiropractic billing: Keeping it simple
Chiropractic billing is like creating a report card for the services you provide. You use special codes, mostly CPT codes, to tell insurance companies exactly what you did for each patient. Think of these codes as a common language that everyone understands. When your “report card” (your bill) is accurate, you get paid the right amount.
Why getting it right matters big time
Accurate billing is not just about getting money in the bank. In fact, it’s about:
- Playing by the rules: Healthcare has many rules. Correct billing means you are following them.
- Protecting your income: Accurate bills mean you are paid for the great work you do.
- Staying out of trouble: Wrong billing can lead to audits and even legal problems.
- Building patient trust: Clear and correct bills help patients understand their costs and trust your practice.
Red flags that scream “warning”
Here are 11 things that should make you stop and think about your chiropractic billing:
1. The copy-paste problem: Same code for every single person
- What it is: Using the exact same set of billing codes for almost every patient who walks through your door. No matter what their problem is.
- Why it is a red flag: Chiropractic care is all about individual needs. Different patients need different treatments. Using the same codes for everyone suggests you might not be describing each patient’s care accurately.
- Imagine: A teacher giving every student the exact same homework, even if they are learning different things.
2. The “why?” question: Missing documentation of medical necessity
- What it is: Not clearly writing down why the chiropractic care was needed for each patient’s specific health issue.
- Why it is a red flag: Insurance companies need to know that the treatments you provided were necessary to address the patient’s condition. If you don’t explain the “why”, they might not pay.
- Example: Your notes just say “adjusted spine” without explaining the patient’s pain, how it limited their movement, or how the adjustment helped.
3. Lost without a map: Inconsistent or missing treatment plans
- What it is: Not having clear plans that outline the goals of the treatment, what you are going to do, how often, and how you will know if it’s working.
- Why it is a red flag: A treatment plan shows that your care is organized and has a purpose. Without it, it can look like you are just providing random treatments.
- Think of it like: Trying to get somewhere new without using a GPS or a map.
4. The “just because” trap: Incorrect maintenance care billing
- What it is: Regularly billing for “maintenance care” (care to keep someone feeling good) without following the specific rules that insurance companies have for this type of billing.
- Why it is a red flag: Many insurance companies have strict rules about when and how you can bill for maintenance care. Doing it wrong is a common reason for denied claims.
- Fun fact: Some insurance companies see maintenance care as preventing future problems, which they might not cover.
5. Code confusion: Upcoding or downcoding mistakes
- What it is:
- Upcoding: Billing for a more expensive service than you actually provided.
- Downcoding: Billing for a less expensive service than you actually provided.
- Why it is a red flag: Both are incorrect. Upcoding can lead to serious trouble, while downcoding means you are not getting paid what you deserve.
- It’s like: Saying you fixed a whole car engine when you only changed the oil (upcoding), or saying you only changed the oil when you fixed the whole engine (downcoding).
6. The invisible service: Billing for care not given or not written down
- What it is: Sending bills or treatments that the patient didn’t receive or that you didn’t write down in their records.
- Why it is a red flag: This is a serious form of incorrect billing and can have big legal and money consequences.
- Example: Billing for a special muscle treatment that the patient didn’t have, and there’s no note about it.
7. Secret language add-ons: Improper use of modifiers
- What it is: Using or not using small two-digit codes (modifiers) that give extra important details about a service.
- Why it is a red flag: Modifiers can change how a bill is paid. Using them wrong can lead to denied claims or wrong payments.
| Modifier | What it tells the insurance company | How it’s used in chiropractic billing |
| -25 | “We did a separate, important check-up on the same day as the treatment for a different reason. ” | When a patient comes in for their regular adjustment but also has a new, painful problem, you need to examine it. |
| -59 | “We did two different procedures on different body parts or at different times.” | These are distinct services if you perform manual therapy on the neck and therapeutic exercises for the lower back during the same visit. |
8. The “no payment” pile: High percentage of denied claims
- What it is: A lot of your bills are being rejected by the insurance company.
- Why it’s a red flag: This usually means there are problems with your coding, documentation, or billing process. You need to find out why.
- Think: If you keep getting a failing grade on your homework, you need to figure out what you are doing wrong.
9. No self-checks: Lack of internal audits
- What it is: Not regularly reviewing your own billing to find and fix mistakes.
- Why it is a red flag: If you don’t check your work, small errors can keep happening and cause bigger problems later.
- It’s like: Never proofreading an important email before you send it.
10. “Not our problem”: Billing for services insurance does not cover
- What it is: Sending bills for treatments or services that the patient’s insurance plan does not pay for.
- Why it’s a red flag: You need to know what each insurance company will cover. Billing for things they don’t pay for will just lead to denials.
- Example: Billing for a specific type of massage therapy that the patient’s plan excludes.
11. “Everyone gets a free pass”: Regularly waiving patient co-pays or deductibles
- What it is: Regularly not collecting the patient’s share of the bill (co-pay or deductible) without a valid reason and good documentation.
- Why it is a red flag: This can be seen as breaking your agreement with the insurance company and might even be considered illegal.
Taking control: Fixing the red flags
Spotting these red flags is the first step. Now, let’s talk about what you can do:
- Educate your team: Make sure everyone involved in billing knows the rules and how to bill correctly. Regular training is key.
- Document everything clearly: Write detailed notes that explain why the treatment was needed and what you did.
- Audit your bills: Regularly check your billing records to find and fix any mistakes.
- Stay up-to-date: Billing rules change. Make sure you are always learning the latest updates.
- Use smart tools: Billing software can help you catch errors and make the process easier.
By being aware of these chiropractic billing red flags and taking steps to fix them, you can ensure accurate payments, reduce stress, and build a stronger financial foundation for your practice.
Ready to simplify your billing and get paid accurately? Wellyx offers chiropractic billing software designed specifically for chiropractic practices to streamline billing and avoid these common red flags.
Explore Wellyx to learn how it can help your practice thrive.