Blog, Live Events February 22, 2022

Are You Medically Necessary?

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

Hi there, friends and colleagues. It’s Sam Collins, your coding and billing expert for chiropractic the HJ Ross Company and ChiroSecure. We’re always here to make sure your office continues to grow and thrive and let’s do it without any risk and make sure your practice is a bit better. Let’s talk about what you’re all experiencing.

Cause I get this question quite. How do I deal with pre-authorizations where they never pre-authorize more than a few visits or never let me get what I really think the patient needs to get better. What is it that the carrier is looking for? Have you ever understood what they look at so we can make sure to provide them what they’re needing?

I won’t say you should compromise what you do, but make sure you’re adding the things that they need in order to give your character. The go-ahead. So let’s go to the slides. Let’s talk about pre-authorization with all of these cares, and you’re gonna see this all over. I’m showing some examples here’s of different ones, the forms that they have, as well as how many visits, but you’ve all experienced it.

Whether it’s Ash blue, cross blue shield, Optum, and so forth, what is it they’re requiring for? Pre-authorization so let’s define. Pre-authorization means a decision by the health insurance to decide whether the treatment planner care is medically necessary. Now you hear lots of terms to bandy about with this.

That will be like it’s pre-authorization prior authorization, prior approval. Pre-certification. Doesn’t matter, all really means the same thing. So we have to start to focus on what is it that they’re looking for? How do they determine the need for care? Because I know from our standpoint and I get this question quite a bit, how come they always cut me off at five or never given me more than six?

Let’s get into the carrier’s mindset of why. And I’m always going to say, let’s turn it on ourselves. Does what we’re providing dictate the level of care we want. So we have to look at what they think though. And we do know this, they state things of this nature, and I’m taking this directly from American specialty health and it’s.

Kara’s focused on rapid attainment of defined objective functional outcome. Now I would certainly agree with that. We want the patients to get well as quickly as we can. And effectively, obviously that’s the end of the day, what we’re expecting. However, we have to make sure what are they looking at and what guidelines, because they’re going to use some pretty strict guidelines, American college of occupational environmental medicine, maybe the official disability guidelines or other evidence-based guidelines.

So you gotta be familiar with what those are. And when you can go beyond, cause you remember when you see an average means everything is perfect. Like an average person with an ankle sprain. Might only need care for a couple of weeks at best, maybe even no care. But what about when there’s other complicating factors or greater severity?

How do they know that if we’re still just using that same diagnosis for spraying? So when it comes to medical necessity, I want you to see what does it carry or look for. And these are going to be the nine things that carriers place importance on that you should to, when you’re making that pre-authorization requests.

The number one thing they look at is diagnosed. And we must be careful to make sure we’re not having rudimentary diagnosis, because those are going to be always difficult to get a lot of care from because there’s simple diagnosis. So think of it. Does your diagnosis fit the care plan? You’re requesting a certain amount of visits.

Does that diagnosis equal? If you think the patient needs 30 visits, does the diagnosis equal that? So let’s look at some diagnosis from this standpoint. Think of yourself in a way when you’re diagnosing a patient. And I want you to think of, are you painting Monet’s or Rembrandt’s Monet’s are beautiful paintings.

However, if I asked you who that woman was in the picture, you would have to say, I don’t know, I can’t identify her, but the one on the right being a Rembrandt is more detailed. And so keep in mind if you’ve ever seen this joke, a lot of teenagers often use, they’ll say someone is a Monet and you might think, what do they mean by that?

You know what they mean? That the person is good looking from a distance because when you get close, it’s not. And I want you to think of kind of diagnosis that way from a long distance back pain is fine, but does it really dictate a care plan? That’s going to equal twenty-five visits. Of course not. So I want you to start thinking of how are you diagnosing?

Am I doing Monet’s that are pain and symptoms? They’re not incorrect. They’re just not very detailed. If I said cervicalgia, great, my neck. Quite frankly, my nine-year-old grads. I could make that code if you will, because someone can say their neck hurts. Oh, describe it. In other words, this is a description of a condition, even subluxation while we’re chiropractors does subluxation on its own necessarily dictate a large treatment plan.

Technically know philosophically I get it, but technically no. So we have to be a little bit more than just that. Now, if you’re going for a few visits, this is fine, but what can cause pain? I think of the reason. If it’s just a headache. Okay. But what about something like cervical radicular, apathy, or how about cervical brachial syndrome next Springs.

Next strains. How about neck myalgia or myalgia of the neck? How about emphasize? Apathy’s the tendonitis coats, muscle spasm, fibromyalgia spondylolisthesis, disc issues. Notice all of these things can cause. But what we all agree, someone with radicular apathy would need more care. So be very careful pain is not your friend when it comes to necessity.

So if you’re coding, one of these things on the right pain is a throwaway. It doesn’t help us because it doesn’t dictate anything. We don’t already know if I told you I have my algebra or cervical radicular apathy, does it help if I say, oh, and it also hurts? Not really. So they’re looking at severity of diagnosis.

So start thinking along the lines of. If you’re thinking your patient needs 20, 30, 40 visits. I certainly possible does the diagnosis. You make someone who sees that immediately go, oh my goodness. Yes. They’re going to need that much. Now grant you they’re going to air more cautiously than we might, but you’ve got to think the same way.

How about the last one? I point out just headaches. When we all agree. Someone with a migraine is going to be different than someone with when we say just unspecified. How about this instead, cervicogenic coming from the neck. So give me a code that better fits the next part of medical necessity is, and they pay a lot of attention to this.

You may not think so, but that’s why they always ask those things about what is the past medical history what’s going on? Is it traumatic? Is it repetitive? Is it acute, severe? Chronic. How about exacerbations? How about if it’s recurrent, think of all these things make a difference. This is the narrative.

That’s why they have us write a short report. Some of you may think, oh, they don’t pay attention to that. They do, but they don’t give you a lot of room on the form. So sometimes you have to put a little bit more, remember that diagnosis. Doesn’t tell us all of that information. So if there’s something complicating it, we have to make sure that it’s.

And by complications, please make sure you’re identifying comorbid factors. Every carrier that does pre-authorization will actually pay attention to complications and comorbidities. These are underlying health conditions that may not be part of the problem, but will complicate recovery. And if you don’t report it, it doesn’t exist.

Think of how many times you’ve taken an x-ray of someone and if you code neck pain, but don’t have. That there’s disc degeneration or decreased joint space with saying a spondylosis or curvature changes. That means no one knows it. So it has no effect. So how about coding? Things like that.

How about acquired kyphosis happens all the time for most people? How about scoliosis or spondylosis? Just meaning arthritis, changes. How often do you see that? Even as someone as young, as 30 years old, start to make sure they see a complete picture. What am I paying for? Would we all agree if someone has a reverse cervical curvature with lipping spring and Ebro nation with even a neck strain or even pain, if you will, would that person require more?

If all you knew about it, that it was painful? What’s the next factor for medical necessity, your physical exam findings. And this is something important that you have to look at because they’re focusing on it too. That’s why they’re requesting that you send them information. So it means everything you do range of motion.

Palpatory findings, orthopedic testing, or neurologic testing. You must quantify these, please. Don’t tell me the patient feels pain. I get that. How severe where’s the locality of it? What does it inhibit them from doing. How does it affect their range of motion? Because those are measured factors and remember pain level by itself doesn’t mean a lot in the way that we typically do it.

If you have a patient tell you their pain is a five, what does that really mean compared to when it’s an eight? So we need some better way of quantifying that. So that way, when they’re looking at the care plan and looking at the outcomes, they can see that the care plan is making the patient better.

Understand this. What if you say there is taught and tender fibers, that is an accurate statement. What does it tell. It’s taught in tender. Now that could be a very little bit of taught and tender or a lot. That’s like saying, if you have money, if you have a dollar in your pocket, you can say you have money, but that’s a big difference compared to if you had $10,000.

So I want a little bit more here so that someone can see the changes. If I put you on a diet, I have to do some way of quantifying how you’re changing, whether it’s by scale, weight, or measuring with the tape. What’s the other factor we have to think of. This is the big one. Functional limitations by using validated outcome.

Every single plan like here does this, you’ve got to get used to doing these because if you do chose your care, here’s what I will tell you. Chiropractic works well, it doesn’t always show up in our notes the way we want, because we don’t have that tangible evidence. So I want to make sure you’re doing something like this.

Take a look at this pain scale compared to the one that most people who’ve been here. The one that we most use is just all over the place. When it’s at its worst, it’s a 10, no, a 10 means you can’t function. And one person’s is different from the others. So we want something more tangible. Notice what number five says here, it says interrupt some activities.

So it’s not about how much it hurts, but what it’s doing compared to what if it’s an eight? I can almost do nothing a little bit, but. I can do it, but it’s preventing me from most of it or a little bit more. So notice this is not as much a pain scale, is it as a functional scale. And since insurance companies look at function, as a result of care, let’s start putting a pain scale together that does this.

Now this is the one put out by department of defense and veterans, but there’s no reason you shouldn’t use that for everyone. And in fact, what makes us a really good. It’s two-sided notice there’s four questions on the backside of it that says, Hey, how has your activities been in the last 24 hours? But notice also sleep, mood and stress.

So looking at the person more holistically. So how about having this day to day where the patient comes in and I won’t even say fill this out. You know what I would do, I would take this type of page, blow it up to a poster and put it on the wall to your honor. Now you may be thinking well, Sam great, but where do I get that?

Do this. I literally need you to take your phone right now. Get your phone. I’ll give you a second. When you get your phone, open up the camera, bring it up to the screen. And when you bring it up to the screen, you can hit a text message. And it’ll say to you, hello, we’re happy to send you the pain scale.

In other words, our gift to you from ChiroSecure and HJ. Ross is this form. You then will send us a text. If you are, by the way, if your phone doesn’t do it, don’t panic. Just text a 7 1 4 2 8 0 4, next 4 6, 9, 7, because it’s important that you make sure your care is necessary. We want to make sure you have the tools, so please make sure to get a copy.

And here’s what I do. You’re going to get an email or a text of this actual form in a nice clean format that you can print that it’s not a copy of a copy as well as you can blow it up any size you want, because I know your care work. But can I always evidence that by your chart notes and your outcomes.

So let’s use that because certainly medical necessity is going to go beyond what we’re mostly typically thinking of. The patient feels better. Give me a function. The next factor is, what? They pay attention to the goals. While if we’re using outcomes, the goals are going to be a little bit more evidenced, but think of something that is, and this is by the way, taken directly from a carrier functionally based realistic.

Measurable and evidence-based so notice everything is function and measure. So just start measuring start quantifying. I would argue that if your notes are slightly weak, as far as the format, if you have good outcome assessments, it’s always your savior because at the end of the day, what are they really paying you to do?

Make the patient better? That they’re not just at a plateau and it’s maintenance, if you will. So think along the lines of functions in ADL’s. If a patient says what. Oh good. Tell me what you can’t do because that’s what we write in this pre-authorization we can show that, Hey, that patient initially came in, they couldn’t tie their shoes and bend down and.

Now they can tie their shoes, but of course they can’t sit for an extended time still, or they can’t reach and fully touch their toes except in a sitting position. Do you notice the difference here? It’s not about how much it hurts, but how it affects their movement and their activities of daily. The final factor is how do you dictate this for your actual care plan?

And I want you to see a couple of things here that it’s important to note. This is not Sam’s idea. I’m taking this directly from the carrier. This is from the signal Cigna clinical policy bulletin. And what it says is this, the provider should attempt to integrate some form of active care as early as.

Continued use of passive care modalities may lead to patient dependency and should be avoided. In other words, what are they actually saying here? We want you to do more active care of the patient than passive. Everyone sees that whether it’s home care, but how about in the office? Because notice it says passive modalities are most effective during the acute phase, since they are typically directed at reducing pain.

Pain is only part of this. We’ve got to get function. So quite frankly, what they’re saying is stop using the passive cheap. Use the more extensive and expensive active care cause it’s better for the patient. Every guideline says it. In fact, take a look at one more. This is from the M and I H it says it has been recommended that passes modalities be not be employed, except when necessary to facilitate participation in active treatment of chronic non-cancer pain.

Is that of the results from traditional passive modalities. It says our. Perhaps this may be due the propensity of patients to seeking out the relief. It doesn’t really make them better. Notice this all goes back to active care. What has chiropractic always done? Focus on the active. So give me something about where’s that diagnosis lead me to what are the complicating factors?

What’s going to make it take longer. Think of all those things, person’s overweight, deconditioned, they’re diabetic. There’s a lot of things. Maybe you’re not even treating it, but the effect, the recovery, if you think it’s affecting the outcome, if you don’t write it down, it doesn’t exist. Then from there, focus on a care plan that focuses on function and active care more than passive realized.

Passive cares. But realize that should facilitate the active rehab part of it. If you do those things, you should do much better at getting care because now you’re dictating because I’m not saying the reviewer necessarily doesn’t want to give you care, but they can only give it if you hit the points that they require.

So let’s start realizing if those are the things they are emphasized and we have to make sure we’re reporting them whether or not those are ones you may always want to. But they’re the ones that they require. And since they’re paying the bill, I want to make sure we do that because what’s more frustrating that a person that needs care that you work on it and they don’t get it.

Now, this doesn’t mean this is going to open every door, but this is going to make a big difference. Really start to be a better student of coding and think of functional outcomes. If you do that, you’re going to resolve a lot of the issues that most people get. Realize a lot of this stuff is already available to you.

Go to our website, HJRoss Company. We have a new section that updates things like Medicare rates increasing. How about the coding changes? What’s better codes. Have you ever done a program that really talks about coding beyond the simple, here’s a list. Let’s do something more than that. We offer a service where I can become part of your team.

Join our network. I’m here to have. I want to make sure you have the right things. Let me help you write that darn thing. Let me show you what works and what doesn’t work. And so I’m going to say to all of you, thank you very much. It’s really important for me to be part of what you do, because I love this practice of chiropractic.

My dad was a chiropractor as am I, and I want to make sure our practice continues to grow and we get more access to people because we’ve got to stop the opioid crisis chiropractic as part of that. Thank you.