Reopening and Revisions of Claims Determinations and Decisions

Updated: April 18, 2011
Dear Doctors and Staff,

I am asked constantly how far back the Medicare Carriers can go when doing an audit.  My answer to them is usually, "You really don't want to ask that question!" 
In most states, we are required to keep our records five to seven years.  That is State Statute.  We are dealing with the Federal Government which supersedes state statute. When you are audited, YOU have to prove your facts for your protection.  If your records are lose.
Reopening and revision of claims determinations and decisions 12100.10 is called Unrestricted Reopening.  A determination or decision may be reopened "at any time" if it was procured by fraud or similar fault, regardless of whether criminal prosecutions have been or will be instituted.  The fraud or similar fault may be that of the beneficiary, provider, physician, or any other person.  It includes several descriptions including...."The furnishing of services in excess of the individuals needs, of a quantity that does not meet professionally recognized standards of health care." (That means.... "If you are unaware how to Document the Chiropractic necessity of care by Federal Standards, the care you provided is NOT necessary, and S.O.A.P. note are NOT documentation in Medicare!!!!)
A claim may be reopened more than four (4) years after payment was approved, if the evidence establishes a pattern of billing by a physician for not more than one visit a month was medically reasonable or necessary.  
BOTTOM LINE: If you wish to learn how to do Chiropractic Medicare correctly, including "documenting" by federal standards, please consider ordering our Chiropractic Medicare DVD and booklet. It explains piece by piece every important step in doing and billing Chiropractic Medicare so there are no limits for the chiropractic adjustment. If you are audited you will have done Medicare correctly and win your audit. You and your staff will be very happy you have this important and mandatory information. I promise it will make a difference in your understanding of Medicare and how you bill Medicare.
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Keep in mind, Medicare is the only insurance type program that if done incorrectly is fraud, a felony, a fine and/or jail.

I promise you will be more than satisfied that you made the right decision to purchase this information or attend our presentation. Please give me a call if you have questions. 1-618-395-3162

Best regards,
Dr. Gary R. Street

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