Beware of the Managed Care Audit
I was audited over a year ago by Horizon Blue Cross Blue Shield of New Jersey. The auditors were friendly - they offered to buy me coffee, and they asked about my family and how I liked practicing.
Months later, they called to tell me that I owed them a "few dollars" and that it was "very, very negotiable." However, they wanted me to come to their office to discuss it because the paperwork was too complicated to send me in the mail. Of course, I asked, "How much?" They told me, "Not much." When I pressed the issue, they finally said it was only about $80K. I asked if I needed a lawyer for the meeting and they said that was up to me, but that the meeting would only be a "friendly chat," so there was no reason to elevate it to anything more than that. I called a lawyer, of course. After I retained counsel, he reached out to the auditors to set up our meeting; they told him the amount actually was closer to $100K.
Then, on the day of the meeting, almost immediately after we arrived at their office, we were told I now owed Horizon $174K. I was blindsided and my lawyers told me many auditors will lull you into thinking these audits are no big deal and then shock the stuffing out of you, hoping to get you to admit something and settle quickly.
Know your rights, namely the right to defend yourself from fraud allegations that are unfounded and used purposely to harm you and the reputation of our great profession. Our auditors only made copies of some of the travel cards we used and then said because they couldn't find other information, I must have made it up, and billed me back. When I sent them all the information, they refused to consider the additional notes, and the overpayment demand did not change at all - still $174K. Even worse, when my attorney hired a fraud/coding expert to rebut Horizon's findings, his report was ignored and Horizon simply stopped paying me, applying money from my current claims to my "balance" with them.
So, here is what I did. I am fighting back. I called a few of my heroes and sought advice. Many people who have been here before, fighting the FDA, were excited to see someone fighting. A chiropractic school president, however, told me to take my lumps and move on (sadly, he is not a chiropractic hero any longer).
So, when (if it is not already a reality) you receive an audit letter from an insurance carrier, call your lawyer; or call mine, John W. Leardi of Buttaci & Leardi here in New Jersey, at (609) 844-7566. They will help you put your house in order. They will explain the rules of the game to you, and can even have one of their coding and fraud consultants conduct a "mock" audit of your documentation, billing and coding before an insurance carrier comes knocking. More than anything, they can help make you ready.
Insurance carriers are on a witch hunt looking for money. I asked our auditor why they don't go after hospitals; after all, aspirin can't really be worth $230 a bottle. I was told that it's not cost-effective because hospitals have lawyers and they fight back. There you go ... chiropractors are being targeted because too many of our colleagues have lied down and taken it, even when a carrier's allegations were baseless!
Stand up and fight. Be completely honest and professional in your record-keeping and know what the rules of insurance reimbursement are. Be a healer and be gracious.
We have fought and we will continue to fight. I filed a lawsuit against Horizon and they filed a counterclaim for insurance fraud against me. But we won't settle. We will have our day in court, because after all, we are right.
And they are wrong.
If you would like to hear more, e-mail me at
or call me at (201) 796-1010. It is a long and lonely road that I am traveling, but it doesn't have to be for you. Stand up and fight for the truth, and I will be right next to you, every step of the way.
Daniel B. Rodis, DC
Fairlawn, New Jersey