232 The Chiropractic Trap

Welcome to the KC CHIROpulse Podcast.  

This week’s topic:  Don’t Get Caught in the Chiropractic Trap

The KC CHIROpulse Podcast is designed for Chiropractic professionals ready to elevate their practice to new heights.  This week, the show is hosted by Kats Consultants’ coaches Dr Michael Perusich and Dr Troy Fox, seasoned experts in Chiropractic business management.  This podcast provides invaluable insights and actionable strategies to help you create a flourishing and sustainable Chiropractic business.

In this episode, we discuss:

• Why proving medical necessity is imperative when billing insurance
• Why clinically appropriate care should never be billed to third-party payers
• Why taking the right steps in your documentation can protect your practice
• Where to find the “instruction manuals” for how to avoid the traps
• …and so much more…

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Transcript

232 The Chiropractic Trap

[00:00:00] 

Dr. Michael Perusich: Let's talk about the insurance traps. Hi everybody. Welcome to the KC Chiro Pulse podcast, bringing you cutting edge strategy on running your business and creating profits. I'm Dr. Michael Perusich This is my co-host, Dr. Troy Fox. We're brought to you by Kats Consultants in Chiro Health, USA, Troy, the Insurance Traps, they're all over the place.

It's like little mouse traps just waiting to snap at you. They are. And quite frankly, our profession is kind of a square peg and a round hole to begin with when it comes to a little bit to insurance utilization. So there are some very easy traps to fall into when it comes to utilization. There are some easy traps to fall into when it comes to some of the Medicare stuff as well, which is kind of a whole different animal, but still insurance related.

Sure. Um, and you know, going to a third party. Anytime. Anytime we look at this, they are, they're really the vendor. We have a patient [00:01:00] relationship and we have a vendor relationship. And in a lot of cases, that's a good way to put it. As chiropractors, we tend to get frustrated. And I'm not saying just as chiropractors, every doctor gets frustrated with that vendor relationship.

They're on one side of the relationship trying to make a profit. They're a for-profit company. As much as you don't like that's who they are. And if you choose to interact with that vendor, you have to play by their rules. And if you choose not to work with that vendor, then that patient relationship is very pure.

But once you add a third party into it, that actually has a say. Over the patient, and they've, they've experienced this before. Uh, there's probably not a patient that walks into your practice that hasn't been di denied for a procedure that was, you know, like a, a pre-authorization procedure that they thought, well, this is slam dunk.

I need this. Sure. And then they got denied for it. So in, in chiropractic it's a, it's sometimes a little bit [00:02:00] different in how it operates. It's almost like a honey trap. And what I mean by that is that we are allowed to go ahead and bill, in some cases, we receive payment for a service provided. 

And then the insurance company comes back later and says, Hey, we'd really like to see your documentation on that.

Yeah. And then. The mad Sues. Yeah. Then we don't like your documentation, so we're gonna take money back. And I like this idea of thinking as of the insurance company as a vendor. 

And you're right, they're, they're a for-profit business. So when they pay you for services rendered to one of their members, they're actually paying you out of their potential profits.

What does that mean? Well, that means they're gonna do everything they can, everything in their power to make sure you get as little of that money as Pulsesible. Because the more they keep, the more profitable they are. It's just how business works. So we [00:03:00] have to remember that it's not necessarily a, uh, coup deante, it's not necessarily a relationship that's born out of trusting each other when you're building the insurance.

We don't like them and they don't like us, so to speak. You know, we, we like the bit of reimbursement that we get sometimes, but we have to be careful with it because there are so many of these traps. And if we don't know what those traps are or have a good idea of what those traps are, they're like stepping on landmines and they will blow up on us and there'll be pain that ensues with recoupments audits, et cetera.

So what we see with a lot of doctors with this is that you sign on the dotted line for a contract with whoever that vendor may be, and you kind of throw it in a drawer. You know, it's all digital anymore, but you know, back in the day when you signed it on paper, you throw it in a drawer. Now you do it digitally and you throw it in a file somewhere.

It's on your [00:04:00] desktop somewhere in downloads maybe, or in documents dependent. You know, you may not know where it's at. Sometimes I, I have to do a, a fun search a lot of times to find stuff on my computer because we tend to, we tend to rat hole a lot of things away. And so those contracts are there. But the question is, have you ever read the contract?

When you got accepted, did you read through the contractual obligations on your part and the comp and the contractual obligations on their part? It is a contract, yeah. And here's the funny thing about those contracts is you signed away, you signed a contract that allows the insurance company to make changes to that contract anytime they want because you signed it.

And so it's not a contract that. That doesn't allow for changes. You know, I hear doctors say all the time, well, how can they change things on us when we didn't sign a new contract? Well, [00:05:00] you signed an open-end contract is what you signed. And so they, they can make changes. And they will make changes.

And even if they're going against the contract, do you have the ability to fight them? No, you don't. It's pretty tough. And quite frankly, their board gets together. And what do they look at? They don't look at you. No, they don't go, gee, let's look at the chiropractors in the state of, and you fill in your name.

What they do is they look at their profit and loss statement. That's what everybody, that, that's how a good business operates. They look at their profit and loss and they go, we're bleeding money right here. Yep. Let's and either one of two things. I'm not saying the insurance companies are evil because that's, that's not what we're trying to purport here.

No, that's not what we're saying. What we're saying is, is that if you were losing money because of a service a provider was giving you, let's say you have, you are. The employer and this vendor works for you. Let's say they're gonna build a fence for you, and you thought the fence should have cost [00:06:00] $5,000 to build, and you start looking at the billing statements and all of a sudden you're up to $18,000 and they've just got Pulsets on the ground, they don't even have any fence up yet.

Right. Which you at that point, audit the contractor and say. Hey, what have you done up to this point? And the contractor may come back and say, Hey, the cost of fencing, the type of fence that you put in has gone up so substantially that the cost of the fence in itself has gone up and it's gonna be roughly $23,000.

Or you look at it and you start looking at the bills and you start realizing that there's a 60 yard dumpster. It's supPulseed to be parked in your front yard that you got paid for or that you're paying for, and it's not there. And there are materials that have nothing to do with the fence that are not there.

So there's both sides of the equation to look at when you look at that. And so the insurance company looks at you and they say, okay, doc, [00:07:00] you did these services. What did you do to come to the determination that the patient needed those services? That's called medical necessity. The trap begins. I wanna, if you didn't do your homework, that's and document correctly.

Yeah. Yeah. I wanna, I really wanna dive into that 'cause you just hit on the one thing that's probably the biggest mouse trap in the world. It also can be your savior. So we're gonna take a quick break, quick word from our sponsors. We'll come back. We're talking about the mouse traps in third party reimbursement.

We'll be right back.

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Dr. Michael Perusich: Alright, everybody, welcome back to the Mousetrap, actually with KC ChiroPulse Podcast, but we're talking about the mousetraps in the insurance world. Troy, before the break, you brought up this concept called medical necessity, and I think probably most people know what that means by now. It's, that's terminology that's been around now for several years, but it's, it's you as the [00:09:00] physician.

Proving to the insurance company that the patient needs, the services that you're billing based on the diagnosis you're billing. So we have to think of our billing as a story. Mm-hmm. And it's a story that has basically three components to it. Here's when the patient's condition started. That's your start date.

Here's what's going on with the patient. Everything that they are experiencing symptom condition wise, that's your diagnosis. And here's everything we're doing to try to improve their situation and most of all, improve their outcomes, improve their unwind their disability, if you will. Mm-hmm. And that's your, that's your CPT codes.

Those three things have to tell the right story. And if you bill a start date that was two years ago and you're billing a sprain strain injury, the insurance company's gonna look at that and say, [00:10:00] how is this a sprain strain injury that happened two years ago? And we've got six different treatment codes that you're billing for a total of about $210.

Why does this patient need all that be? And what they're looking at is a very disco congruent, that's a word, right? Yes. Mm-hmm. Disco congruent story. Incongruent. There you go. It's not consistent. How's that? Yeah. It's like if a cop asks you when you were at the murder scene, what your story is, and it doesn't match up, it's like, okay, this just doesn't match right now.

And here's the thing, docs, I know sometimes we feel dirty when we get told that's not medically necessary. Maybe your documentation was up, wasn't up to muster. Now does that mean that it wasn't clinically appropriate? Absolutely, it could be clinically appropriate. Sure. So we're not saying just because your note didn't meet muster that you shouldn't have treated the patient.

What we're saying is no, [00:11:00] not at all either. A, you have to meet the documentation for medical necessity, or B, it might be something that's clinically appropriate and the patient needs it, but the insurance is not gonna pay for it. And that's a trap we get caught into in a lot of cases, is where we think if it's clinically appropriate.

That is a term synonymous with medical necessity. And it's not. It's not. It's not. And so how do we find out what medical necessity means to every insurance company? I'm gonna give you a big hint here, and you might wanna write this down. It's the medical policy. Or if we're talking Medicare, it's the LCD, local coverage determination.

These are fantastic documents. However, it's kind of like a set of instructions that you get with your IKEA furniture. Sometimes we just don't wanna follow it 'cause it looks too daunting. Right. But I'm telling you, if you will download those for each insurance company and read them, [00:12:00] they're chock full of so much great information.

Everything from. What over utilization means to the insurance company, the codes that you can build based on your taxonomy, that's your profession. So chiropractic for us, it tells you, uh, it gives you examples of what they wanna see in notes based on different conditions. I mean, it, it basically is your, your kind of little instruction manual for that insurance company.

And all the insurance companies have 'em. You just have to go find it and you have to download it and you have to read it. It's a three step process. And, and if you don't, then again, it's kinda like the IKEA furniture. It's like how come I got all these parts left over and my furniture won't stand up?

It's 'cause you didn't follow the instructions, right? And if you've ever been considered by an insurance company an outlier, you darn well better understand what that medical policy is. Because if you're an outlier, it doesn't mean that you're not meeting medical necessity with the patient, but it means you're [00:13:00] gonna get increased scrutiny.

Because you're an outlier. I mean, that's, you know, it's no different. If I were, again, going back to the contractor situation, if I were building three different fences of the exact same size at three different locations, and we came back with three wildly different quotes for it, I would probably question the outlier, right?

I'd be like, why is this guy so much more expensive? Why did they do so much more work to get the same outcome? But if they read your notes, and like you said, if they read like a story and you've got all the components there, the diagnosis makes sense. Then all of a sudden it's like, oh, gotcha. Insurance companies for the most part, can't just deny just because.

They really, they, they really are looking. Now, I will say that in a lot of cases, insurance companies will deny when given an opportunity because they're a for-profit company, a great exam, a great example of that, and this is [00:14:00] not in chiropractic, but long-term care insurance. My dad has it, and my dad made the mistake of saying, well, if I sit on the edge of the bed just right, which puts him in a precarious Pulseition where he could fall, I can pull my pants on.

Guess what that ended up being a denial of benefit. Denial. This case was closed because my dad was a proud man and said that he could do that. So sometimes just a few words even in your notes. Yeah. May negate payment. And here's the other thing, medical necessity. Just because you've proved medical necessity, doesn't mean you have unlimited care.

Yeah, so we have to remember that our diagnosis is what dictates how many treatments, how many times you get to see the patient. And it's in a relative term, but you know, I can tell you, for example a sprain strain injury that I see a lot of doctors love leading with. I don't know why it's typically like a three to six, four to eight visit [00:15:00] care plan.

Well, if that's all your patient needs, then great. That's fine. But if the patient actually has sciatica and some other things like that, we need to think about the diagnosis that we're leading with, because that's gonna set the tone for how many visits you give before you become an outlier. Well, and a sprain strain diagnosis as well is not one that lends itself well to, I bent over to pick something up off the floor and couldn't stand up.

So the patient's subjective portion of this leads into this as well, which leads me into a little side topic, if you don't mind, that I diverged for just a moment into Medicare. I wanna talk about Medicare for just a sec. Oh, everybody's favorite thing? Medicare. Yeah, which, perfect, because it's October, so yeah, Mediscare.

So what we see in Medicare is this, we see in a lot of cases that you have a patient that has worked all their life. To have this Medicare coverage and you believe they deserve it. They believe they deserve it, they should get care and they should get care in your office. [00:16:00] And they have some owies and some aches and pains, and so they come in on visits one through three, and you give a cervical diagnosis.

And you document it. Well, my gosh, you did a great job of documenting. We know exactly what's going on. Range of motion has been impacted. The ACT activities of daily living. This patient can't even sleep at night because their neck hurts so bad right now and they surely can't hold their grandchild. Man, we've done a good job of documenting what's going on with this patient.

We put a proper diagnosis on it. We treat 'em several times. Yep. That resolves. They are a one. They think you are the best doctor ever. You decide at that point wellness care would be appropriate for you? So far we are on the right track right now. I say I'm gonna see you in two weeks or three weeks or four weeks, or whatever that number looks like for a wellness visit.

Yep. They come back in for the wellness visit and you [00:17:00] at that point have had them on Medicare. You haven't had the conversation that wellness isn't covered by Medicare. In other words that there, it needs to be an active, it can't be a GA modifier, right? So what we see that happens, it's really unfortunate, is after that great workup that you did for the cervical spine, you ask the patient how they're feeling.

Oh, you know, I'm feeling pretty good. My neck feels great. I have had a little tweak in my midback though. Wonderful. Says the doctor. Oh no, I know where you're going. And they treat the patient and change the diagnosis to a thoracic diagnosis that's called code switching. That is the easiest way on the planet during the audit, during an audit to just get absolutely hammered.

Doctor, you didn't do an exam. You didn't even denote that there was a thoracic problem in the initial, and if you did, you didn't do an exam on that. You just went into it blind and said, oh, [00:18:00] now they have a thoracic diagnosis. And if you really follow the deck of cards, if you've ever seen cards set up and you hit one of them and they start falling.

Now we switch to a lumbar diagnosis next visit, and then maybe back to a cervical visit and then back to a thoracic, and you're getting paid like clockwork. That money's coming in. You'll get paid every month. And then eventually you get this letter that says, Hey. We'd really like to see, you've been treating this patient once a month or once every two weeks for the last eight months.

We'd like to know what you were treating 'em for, and then all of a sudden we get a menagerie of diagnosis codes with the same three to four region adjustment treatment code that we've been getting since the beginning when we didn't document any of those other areas. And that is how you fall into the trap.

Unfortunately, that's the trap. It doesn't matter that you believe that Medicare patient should get their care paid for. Medicare, on the other hand [00:19:00] says, that's not what should happen. They should be taken care of for active treatment. It doesn't matter that you disagree, that they shouldn't, that, that, that they should pay for x-rays and they should pay for exam.

I think we're all in agreement on that. Every one of us. Sure. And every one of us is in agreement really that Medicare patients should get their wellness care or their palliative care. 'cause most of it's palliative look. I mean, honestly, our Medicare patients in a lot of cases are not wellness. It's more palliative care.

But is that active care? No. And so here we are a foul of the rules because we have decided, like you said, to throw the instruction manual to the side because we think it's too complicated or we don't agree with it. And we found a workaround and it just doesn't work that way. And folks, that's how you get in so much trouble because you were afraid to have that conversation with the patient about what Medicare really does and doesn't pay for.

And it's okay to have the conversation. And you know what I, I'm here to tell you, all day [00:20:00] long patients will pay for the care they need. If you just explain it to 'em, they'll, they'll pay for the exam. I hear a lot of you out there say, well, I don't do exams on Medicare patients 'cause it's not covered and, and I want to do the patient a favor.

Okay, let's break that down. Number one, did you actually do an exam on the first day and you just didn't charge 'em? That could be enticement. So you can't do that. You should charge 'em for it. And are you not doing progress exams? Because Medicare doesn't cover it. You, you don't wanna charge the patient.

You can't do that because now you put yourself in a trap because either you're gonna be treating the patient too long under. First diagnosis, or you're gonna, like you said, Troy, you're going to be changing your diagnosis and trying to switch out of it every couple of treatments or months or you know, whatever your cadence is.

Dr Troy Fox : Mm-hmm. And 

Dr. Michael Perusich: if you didn't have an exam, then you didn't prove medical necessity, and that's the trap. So to prove medical necessity, you gotta have an exam. And quite frankly, I would [00:21:00] probably, even though Medicare will deny it, I'd probably bill the exam so that Medicare sees that you did it. When you bill it, make sure that you did do it.

'cause that's the other trap. You can't bill for things you, you you didn't do, obviously. But, um, that's a whole different trap. But, you've gotta tell the story and the story has to be congruent. And if it's not congruent and it doesn't make sense, here's what happens. You'll get paid because the department you send your claim into, they have a finite amount of time to turn that back around and pay you.

That's the law. Or they have to pay you interest, but. They're not the department that decides whether or not it should have been paid. They just pay it based on what you sent in. They're basically just the robot section of the insurance company, if you will. But then your claim goes to a different department and they use these models.

Most of 'em are AI generated anymore, so they're incredibly sharp and they're looking. For your [00:22:00] mistakes. They're looking for your incongruencies. I said it right that time. Yeah. And when? When they find it, they get the letter that you get the letter that Troy was talking about that says either you're an outlier or send us the records on that patient.

And then it's a different department from there that decides whether or not you are committing something that might have been fraud and they're gonna come in and do a full blown audit. So just because you're getting paid that to me is one. One of the other big traps is thinking that you're doing it right just because you're getting paid.

That has been the misnomer for. 30, 40 years at least. Yeah. And it, it's such a trap. And you know, like you talked about, each different department looks at this differently and with different tools, using AI nowadays, basically they're looking for, and they're gonna find those anomalies very easily.

Now, if they ask you to send a set of records in, and your records [00:23:00] are impeccable, which is a struggle for us, right. Record keeping is not easy. We're not saying, gee, we have the answer. This is really, I, I do have the answer, but it's, it's grindy. It's a very grindy answer. If you wanna work with insurance, you gotta grind.

Yeah. 'cause you have to really work at medical necessity. And if you don't. Your whole livelihood could be on the line, your family could be on the line. This becomes a very big deal. Now, does it mean that you're gonna end up in the federal slammer? Probably not if you're an individual practitioner, but you might get fined a substantial amount and.

If you live in any kind of small town or anything like that, the, uh, the word will be on the street, which is gonna harm your reputation. And that's something that we don't want either. So doing it, the no, doing it the right way is the only way to do it, because that just is, it's just a, it's a sandwich that you don't want to eat.[00:24:00] 

You know what I mean? I mean, it, it, it's, and my, yeah, and my frustration is, is I see docs out there all the time that, unfortunately, doc, not only do they not understand, they don't want to hear, having your head in the sand doesn't make it any better. No. And I, I see that way too often where we'll talk to somebody and go, Hey, listen, here's what's going on.

One, it freaks 'em out. When all of a sudden you exPulsee what they're doing. Yeah. And they may have already had an inkling that what they were doing is maybe, maybe a little bit in the gray area. You know, maybe they, maybe they treated that patient a few more times than, than they felt maybe was medically necessary and they knew it.

Or maybe they were doing the, some code switching or maybe they're not charging for exams, any of the litany of things that you can do, but then you call 'em on it. There's usually an excuse or a reason, and one of those reasons that I really hate to [00:25:00] hear is, well, I've got a friend down the road that's been doing it for years, and he says that, that's perfectly legal.

Use that and that's great. A lot of prison. A lot of prison cells hold two people. Yeah. So, and again, like Troy said, we're not necessarily suggesting that you're doing something that's gonna put you in prison, but. But you may not get paid. You may not get paid. You may even worse yet, at least I think it's worse, is to have an insurance come back on you mm-hmm.

And take money back that they've already paid you. I'd rather they didn't pay me because I, I can handle not being paid because there are other mechanisms for me to generate revenue via the patient and making services cash. And that's a whole nother topic. Now is, is there a way to beat an audit?

Absolutely. And it's with good notes. I've beat an audit before it. It's with impeccable notes. Yes, you can. You gotta, and they will pick at some of the smallest things when they [00:26:00] find that your notes are very good because they'll job is to find any holes in your notes. And you know what?

Sometimes that's a really good learning experience and it's a very painful learning experience. If your notes are not good. It's horrible. And so what constitutes a good note? A good note is one that's proving medical necessity for the condition that the patient has with proper goals that are set to restore function.

Remember chiropractors, we don't treat pain, we get people out of pain. I get that. But our, our job in removing the interference of the subluxation. From an insurance company standpoint, the medical necessity C component is to restore function, and so once we get 'em back to function, we probably, in most cases, shouldn't be billing the insurance company anymore because.

In their eyes. We've done our job. Now, does that mean it's not clinically appropriate to treat the patient beyond that? Heck, yes it is. Yeah, of course [00:27:00] it's pour the power of chiropractic all over the patient at that point and get 'em into lifetime care, whatever that means to you in your practice.

Maintenance care, wellness care, lifetime care, basically all the same thing. We all, you know, I realized some of us handled a little bit differently, but that's where. That's where we get to really have an impact on the patient is when care becomes clinically appropriate. That's my opinion because in the beginning when we're billing the insurance what we have to do to, for the insurance company to like us enough to pay us is to prove that we're restoring function.

Okay, so, and there's so many ways to do that. When you look at that, it's not just your orthopedic testing, it's range of motion testing. It may be right, you know, it may be, uh, kinesiology, it may be resistance. It can be functional movement, which I know that's being taught in the colleges right now.

Right? Those functional movement screens are fantastic for showing that the patient still has loss. Like I had a patient that came in the other day that [00:28:00] had no idea that he had a problem. Where he thought the problem was was, and those of you that have done functional movement screenings, understand where I'm coming from.

He thought the problem was in a specific location. We did the screen, realized it was in a different location, and that it was, it was substantial. He was blown away when he saw it. Now I can't just blow him away. If I'm billing insurance, I have to document it and blow the insurance company away. Yeah.

Here's the loss, here's the loss of range of motion in this area. It should be 50 50 or whatever it should be. If we're talking about, like, let's say we're talking about a cervical a cervical, thoracic and hip mobility, and you have the patient turn and look behind them, well, the hips should be 50, the shoulders should be 50.

Now I can document. The hips are 50, but the shoulders are 20. We know the problem's up there, we delve in deeper. But the time you do a functional movement screening, you've got all these little tidbits written down with ranges of motion where it's painful and [00:29:00] lost range of motion, or lost range of motion.

We know at that point whether it's a mobility or stability issue, and we're able to document all that so well, that's what they're looking for. They wanna know that they're not gonna say, Hey, what is their pain level today? They're gonna say, are they functional? Right? And did you document it?

If you didn't document it and all you're doing is putting pain level down, guess what? When they get down to a one, you're done. Yep. And maybe before that, because it may, if it takes a long period of time and you've gotta sprain strain diagnosis, it's six months later you're still treating that. Well, that goes back to what we talked about before.

So using the tools that are available for you to objectively. Pattern this. And that's something that I think we're seeing more of with our younger students that are coming outta school, have that opportunity. And I think some of us that have been around the block a time or two, like you, not me, I mean, I'm young still, but, but like you're really taught that [00:30:00] way.

In school. We, we were taught basic orthopedics and some range of motion, but when we got out in practice, was it really something that was, that was. High on the list from a standpoint of you need, this is how you provide documentation that provides medical necessity. Nobody ever really said that.

They just said, oh, you wanna know if somebody's got a sciatica problem, do a straight leg raise. You know? Right. Or do a well leg raise, or whatever you, whatever your orthopedic was. Oh, okay. This is how I do this. Well, okay, well what if it, what if the, and we all know this. We've seen straight leg raises be negative.

Even though the patient's Pulseitive, right? Right. So that's my problem with orthopedics alone. Gemini loves me right now. It's trying to talk to me. Love loved me a lot. It was actually giving me an answer. It was. That's funny. Yeah. But so even Jim and I knows the correct [00:31:00] answer on this, but, but even the absence of it, it says, doesn't mean that you don't have a problem.

Right. So, oh my gosh, that is hilarious. That's too funny. So the functional movement screens are one way to do it. You can look at range of motion. That's an old school approach to it. I think functional movement embodies range of motion, but does it in in multiple patterns. But we were never taught that years ago that this is how you medical necessity, step one, do this, document this.

This is how you get to this diagnosis. I think we're doing a lot more of that now and kudos to you guys that are doing that. But for those of you that are not doing that, I highly recommend that you look into a better method. Of documentation that's quick and easy. A functional movement screen takes two to three minutes.

Now, if you have to go down the rabbit hole on a couple things, it takes a little bit longer. But isn't that still a fairly quick exam when you do that? Sure. I mean, that makes sense. And at that point, you [00:32:00] actually have something that resembles a Kevlar vest that you're wearing at that point. Yeah.

'cause it's it may not be bulletproof, but it's bullet resistant. At least, at least, you know, and it helps you in that, in that audit sense. Agreed. So we need to take another quick break, but when we come back, Troy, I wanted, I wanna talk about or add on to, 'cause you, you already just started it a little bit more about what it means to build medical necessity into your notes and what to do when medical necessity stops.

Dr Troy Fox : Mm-hmm. 

Dr. Michael Perusich: And, uh, kind of finish up this whole idea. So we're gonna take a quick break. We'll be right back.

Pat's Chiropractic consultants, your partner in chiropractic success. We are dedicated with one-on-one guidance to bring you all your practice management needs. Let's supercharge your practice. Give us a call today.

Dr. Michael Perusich: [00:33:00] Alright everybody. Welcome back to the KC Chiro Pulse podcast. We are talking about the traps in the insurance world, traps in your documentation. There's all kinds of traps, but. Gosh, if you know where they are and you know how to look for them and you know how to avoid them, you can live and practice pretty bulletproof and stress free.

Mm-hmm. And so we've been talking about this idea of medical necessity. And medical necessity is something that, like it or not, you have to prove it. And the way you prove it doctors is you prove it through your exam. So a regular cadence of an initial exam followed by. Progress exams, and I don't mean progress exams that happen twice a year.

Progress exams should be within about six visits or 30 days, whichever is less. So make sure that you're building those in. If you're doing, if you're billing to the patient's insurance, if you're not billing to the patient's insurance, fine. Get 'em off on a different program. Put 'em on achu type plan if you can, [00:34:00] and charge the patients cash.

Plenty of patients pay cash for services. So don't think that insurance is your only way to generate revenue in your practice. 'cause it's just not. Let me interject real quick. Yep. You have to be bold if you're gonna do, and you have to have a good exam if you're gonna do re-exams. In other words, if your exam is trashed to begin with.

It makes it really hard to justify that you're gonna do a re-exam. But if you're doing something like we just mentioned, like a functional movement screen or something like that, mm-hmm. You have something to follow up on. The patient understands that you're gonna follow up on that. And there's a reason, what I have heard from a lot of people is, well, patients come in and they've never been re-examined by a chiropractor, and so they're upset that I'm gonna charge them for a re-exam.

First off, explain what you're doing and why. Mm-hmm. I mean, that's a very simple way to do it, is we're gonna do a very in depth workup on you, and then we're gonna need to follow up to determine what your improvement has been. We're not gonna base it just [00:35:00] on pain, that's a problem. We've run into chiropractors.

We wanna base it on pain. What I want you to do is base it on pain. Something objective that you can functionally identify that actually works. Yep, and that's exactly where I was going. Create objective. Testing maneuvers, whether it's your orthopedic tests, neurological tests, and I'm with you, Troy, on some of the orthopedic tests.

Yeah. Uh, functional movement tests, functional movement screenings those things are great. Use your outcome assessment tools those disability questionnaires that everybody hates, but I'm telling you, it gives you a scoreable disability and that's great when you're tracking outcomes for the patient.

Um. And setting up goals for the patient. So make sure you're putting those tools into place whereby you can measure where the patient is on day one and objectively measure the patient's progress or lack of progress 'cause some patients don't see progress as treatment goes. And when you [00:36:00] get to maximum chiropractic improvement, maximum medical improvement, whatever you wanna call it.

When you get to that point, discharge the patient from their insurance case. Don't be afraid to do that. Don't play the monkey game of changing the start date. Throwing in a new diagnosis, not proving medical necessity 'cause you didn't wanna do an exam for whatever reason. Don't fall into that trap. If you don't wanna do the exam, move the patient to cash.

Take yourself off the radar screen you're doing not only yourself a favor, you're doing your staff a favor. 'cause you're gonna keep the doors open, you're gonna keep your revenue flowing and you're doing the patient in a favor. 'cause you're still gonna be there to treat 'em. We're not talking about doing anything unethically here.

We're talking about just following the rules. And how do you know what the rules are? Read those medical policies. I can't say that enough. When you're doing this from a cash standpoint, you still have an obligation from a state level, whatever state you may live in. Oh, absolutely doesn't. And I know you weren't saying they didn't have that, but that's one caveat, right?

No, it's a great point. You [00:37:00] can't just all of a sudden go, Hey, I'm gonna put a cash jar out in the front of my office and I'm just gonna provide adjustments. No exams. Now you can't do that. No. You are a doctor. It says it right in front of your name, and you are bound by the in, in my state, the Board of Healing Arts and right.

I'm bound to follow what their regulations are as well for at least meeting that minimum standard for record keeping for a patient. Yep. Yep. No that's absolutely right. And we're saying a, a multitude of times, so being cash doesn't mean that you don't have any rules to follow. That's not, not the case at all.

But if you're gonna bill insurance just do it correctly. We just want everybody out there to enjoy practice and, and do great things for your patients and so forth. And if you wanna build an insurance. Great. Just do it honestly. Do it ethically. Follow the rules and you will stay out of trouble.

And if you feel lost right now and you're like, oh my gosh, I don't know if I'm doing [00:38:00] it right, doing it wrong. This kind of scared me a little bit because I'm not sure my notes are really adequate. Feel free to contact us and. You know, anonymously, you're gonna need to, you're need gonna need to black out the names of, of who's on the notes.

We're gonna need a generic note from you, but feel free to have us take a look at your notes and determine. Whether your notes are at least close. Now, can we guarantee that you're gonna meet Muster? I wouldn't say that we could ever guarantee that because each insurance is a little bit different.

But you tell us which insurance company you're working with, get us information on what their requirements are, and we go through your notes. In a lot of cases, unfortunately, guys and gals. We see these, it isn't even a question. We look at it and go, here's a huge gaping hole. Here's a huge gaping hole, and we can help you close those holes.

Mm-hmm. But we're not there to just nitpick a really good note and go, you know, you have a really good note, but No. But if you feel like you're a little bit [00:39:00] concerned after seeing this today, feel free to reach out to us. Absolutely. And I, I don't know if it's still available, um, when you hear this podcast, but, uh, we recently did a, a virtual seminar on compliance and bulletproofing your practice.

And that may be something, if it's still available, that may be something you wanna plug into and, and watch as well. But, uh, when you have a chance, go to cats consultants.com and check out all the stuff we're doing for doctors to help. With compliance to help build medical necessity into your documentation, to help become more profitable in your practice, to attract more quality patients to your practice, to build a long-term wellness practice, whatever your goal is.

Those are the things that we do for doctors. We're not a one size fits all. We are a customized business consulting platform for chiropractors. Why chiropractors? Because we're chiropractors too. We wear the same shoes you do. So Troy, anything else to add? I think that's good, other than I want to tell you guys, hey, if you're listening today, you're [00:40:00] probably already doing a good job.

You may not be doing a great job and you wanna get better, or you wouldn't even be listening to us. And so kudos to you for tuning in today and listen to this. That's the first step to making a step forward to medical necessity or better note taking and bulletproofing your practice for your family and for yourself.

So that's awesome. I'm glad you guys were here. Yep, me too. And be sure to share the podcast with your, your friends and colleagues as well. So, from all of us here at Kats Consultants, we want to thank Chiro Health USA for being one of our sponsors as well. We'll see you guys next time. See ya.