Blog, Chirosecure Live Event January 9, 2022

A New Year Doesn’t Necessarily Mean a New Treatment Plan

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Hey everyone happy new year. My name is Michael Miscoe with Miscoe Health Law, and I’m here to present a, what I think is the first Growth Without Risk presentation for the new year. And in recognition of the new year, I’d like to discuss something that has been an interesting phenomena that somewhat confounded me over the years of my career.

And that is. The magic of how a new year and a new benefit year equates to, a new treatment plan and new billing to an insurance carrier where there potentially, or in most cases, isn’t it been no change in the patient? So the title of this presentation in new year doesn’t necessarily mean a new treatment plan.

And what I want to get across is for those of you that are still billing, third party payers who have. Benefit plans that have a certain number of visits per year. First of course, just because a patient has 12, 20, 50 infinite visits doesn’t mean that everything that you do gets to be built or build up to that limit of visits, and then they become cash because they’re out of visits.

And similarly, just because it’s a new benefit year and the patient has a new bucket of visits doesn’t mean that you get to use them.

Fundamentally, I think we would agree. Or you could agree that you can bill a an encounter or services to a third party payer on behalf of a patient especially where you’re participating only when the services are medically unnecessary. Unfortunately as you’ve heard me tell you over the years, that term means something very different to you as a physician than it does to a payer and essentially it boils down to, I will accept the fact that everything that you.

Is clinically appropriate and necessary from a clinical perspective, medical necessity, however, is a reimbursement concept and pair rules regarding what they determined to be medically necessary are purposefully designed to limit their obligation, to pay for things that are routinely done, especially in the area of chiropractic.

Worst. I Any patient with a subluxation has a need to be adjusted. And as true as that may be, that doesn’t necessarily mean that third party payers are responsible to pay for those adjustments. If they did, they’d go broke. The cost of infinite chiropractic care simply to treat subluxations w would make healthcare benefit costs.

Unaffordable for the insurance. So they limit what they pay for. They require associated neuromusculoskeletal conditions that are causing functional deficits. There’s, burdensome documentation requirements where you have to demonstrate, a schedule of care that is likely to result in functional restoration, you have to have objective, measurable goals and all this stuff and all of those rules are designed.

What they are obligated to pay. And if you bill for that stuff and you get audited later and they determine, huh, this patient was being treated for several months on a cash basis. And January 1st, nothing happened to the patient. They didn’t have a wild time, new year’s Eve and, slip and fall on the ice, or, decide to go bungee jumping out of a tree and hit their head.

It’s just January 1st and now we’re going to start billing out of their 20 visit bucket until we run out of visits and then we’re going to stop billing. And interestingly enough that data profile is very easily ascertained by payers because they see all the compensable visits for the most part front-loaded or they see a patient or a lot of patients, all of a sudden starting billable courses of care in the month of January and in.

They’re going, huh? Wonder what happened? So they do audits. They look at the notes and the notes are, the patient presents today and there’s no real mechanism of injury and yeah, there’s some symptoms and at best, maybe the care looks palliative. Maybe the visit schedule as we discussed on one of our prior presentations does not include.

Oh, a restorative course of care. Maybe it’s once every, or maybe once or twice a week. It’s episodic things of that nature, in which case, it gives them the opportunity to determine that the care is palliative and take the money back. This new year in this new bucket of visits or potentially allowable visits should not entice you to run to, oh, Hey, it’s January 1st.

And we can start billing, always think about the medical necessity implications and whether your documentation supports usually they’re going to look for evidence of an acute injury. That’s severe enough that it’s causing significant functional deficit. And which your plan of care is oriented to creating measurable outcomes and you’re tracking actual improvement toward those goals.

And that the patient is compliant with the treatment plan and all of these things that, that compromise our ability. To win medical necessity arguments in post-payment audits. So be very cautious, if in fact the patient, had some kind of slip and fall or some trauma or something.

Yes, certainly. And if you’re in the billing game and you’re willing to do the documentation, knock yourself. Do your deliberate course of care may be out of their 20 visits. You use, six or seven of them and you move the patient to cash and waiting for the next disaster to befall the patient.

If your profile indicates that everybody with 20 visits gets 20 visits and then they’re gone. Trust me, sooner or later, that’s going to get audited. And it’s probably not going to turn out well because medical necessity cases are the absolute hardest to defend without some serious documentation.

And unfortunately, EMR systems aren’t built to create that document. The basis for your new plan of care. As I mentioned, start with, there’s gotta be a new acute injury use. That is it’s the safest indicator, but beyond simply recording the fact that there was an injury. Okay. Make sure that you’re making note of what type of functional limitations use outcome assessment.

Okay in your reevals redo the outcome assessment forums comment on actual changes in the patient’s functional status as a result of treatment. That’s how you’re going to sell care with respect to each and every therapeutic intervention, the manipulation, any therapeutic modalities or procedures, make sure that you add.

Orient the performance of that procedure to a condition that you identify on examination. Number one and number two, don’t duplicate therapy. So don’t use two therapies to treat the same problem and three, make sure you detail with sufficient specificity. You know what your order for that therapy is, especially where you’re delegating the performance of a therapy to a, an unlicensed.

With respect to procedures being mindful of, documenting one-on-one contact and all of that other that this specific time got a case right now, or yes, the doc always documents. I performed 15 minutes of this and it’s just one of those things. Nobody believes it was never 14. It was never 16, so be precise, when you’re documenting time. Documenting your skilled intervention, one-on-one contact all that stuff has to be there. And unfortunately, the documentation burden associated with medically necessary care is so severe that many providers are just battling and declaring their care to be palliative, preventive, maintenance, and stick them with cash.

But if you’re. Playing and run on the insurance hamster wheel. Make sure you follow the rules and understand that with the new year new visits, there will be a lore, especially because the patient says, Hey, I got 20 visits. Why are you charging me cash? You gotta be able to explain to them, you don’t get 20 minutes.

They will only pay for up to 20 visits if they’re medically necessary. This is what that term means to your payer. And your circumstances are such that I can’t make that argument understand when you bill in the commercial insurance world, in Medicare, you are making a statement that the care is medically necessary.

In which case you need to have the documentation to back that up. And while I wish we had 90 minutes for me to explain what that looks like with. Bowls and all of that. And at the end of it, you would be so horrified that you would realize that creating that documentation is too burdensome or even getting close to it is so burdensome that it probably wouldn’t be worth the effort.

But just understand from a risk management perspective, your data profile is how payers decide who to audit. So be very cautious about moving patients into billable care, just because they have new visits because it’s the new year. If there isn’t a reason to do it, don’t do it. Now. Something happens in March or April or may fine.

Okay. But the dispersity of when patients initiate care under a new benefit plan year that alone will diffuse your profile, such that. It becomes less likely that you’re going to get audited at the end of the day. If you were to get audited, you either have the documentation or you don’t. And if you don’t then w you know, we’re gonna have a little bit of a difficult time explaining.

What the reality of the treatment and the circumstances were the benefits achieved from the care. And it depends on the level of sophistication of the payer auditor and how hard they’re looking at medical necessity issues. A lot of those issues can be a sidestep to Fitz a relative. Short duration of care, the services are well-documented in the injury as well.

Documented. Usually that might be enough to get you over the hump and avoid any serious medical necessity challenges. I mentioned with respect to documentation tips, think about your history of present illness for each region that you’re going to treat, identify the impact. Of the context or the mechanism of trauma.

That’s key duration is key. How long has it been? How long were the symptoms written, present? They may have had chronic neck, mid back, low back symptoms over the years. And you can address that in your past history. But what I want to know is when did they change? How long has it been since the change?

What caused it that. Then almost mandatory. Gotta have it. If you’re thinking about entering into a billable course of care, talk about associated signs and symptoms modifying factors. It’s fine to say that chiropractic treatment has been effective in the past. That’s great. But in reality, what I want to rule out is that Motrin will.

Okay. And if the patient’s tried inseds or over-the-counter medications and got limited effect, then fine say that that helps justify why we’re doing more expensive chiropractic and physical medicine care. As you embark into care, focus your documentation on what impact the care is having on the patient’s condition and be sure to go beyond visual analog scale tracking a declining VAs is wonderful.

It means the patient has less pain but you’re pretty much proven the point that your care is palliative or at least that’s all I can tell in terms of an impact. Don’t forget to talk about function either through specific functional activities where the patient has improved capacity for bending improve range of motion increased sitting capacity by certain percent use quantifiable statements of improvement, wherever you can.

The alternative is to use outcome assessment. And yes, I know patients don’t like filling out these forms, but if they want the insurance company to pay for their care, you got to tell them that it’s important and that they need to do that long story short. Watch your data profile avoid the billing of the wants, going, starting January 1st and starting into once a month and bill and a visit every month.

I That’s going to get identified very quickly. And watch, how many of your patients you integrate into a new plan of care in the month of January? It’s going to be difficult for their computers to believe that everybody suffered a traumatic injury in January and needed to start a new course of care and it magically, they were done when they ran out of visit.

It’s very easy for there. They’re computer programs that analyze data to identify in which case you may become the unfortunate target of a post-payment audit. And look, if you never have the need to call me, that’s a good thing. Keep that in mind. And if you do get audited, some of those documentation tips will make it a much easier defense in terms of mitigating whatever the overpayment liability you have.

Especially with respect to documenting your, the procedures that you’re performing with specificity location time, if it’s stem, frequency, settings, all that stuff make sure that’s in your documentation. Develop standard orders. If you need. Next week Dr. Sam Collins is going to be back and he’ll have, I’m sure a very interesting coding and billing topic for you until next time.

How everybody have a great process and audit free new year. See you next month.