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Okay. Hi everyone. My name is Michael Miscoe with Miscoe Health Law, and I’m here to present, uh, today’s installment of the Growth Without Risk, uh, series. And today we’re going to talk about, um, two things, comparative billing reports, uh, as well as, um, indicators of a post-payment risk and the things that payers look at, uh, when evaluating, let’s start with CBRs. Uh, first, what is a CBR? Um, it’s an acronym for comparative billing report. Some, uh, payers, uh, call them different things. Um, I call them shots across the bow. Uh, usually these go out, I believe, uh, blue cross blue shield of Illinois just sent out 5,000 of them, um, to providers of various specialties recently. And essentially when you get one, uh, you need to pay attention to it. Um, most docs don’t because it’s not a demand for money and it’s not a check.
Um, in which case, it sort of goes off to the side as an unimportant document, but, uh, you need to pay particular attention to these things because they tell you, uh, where or particular areas that, uh, that particular payer is looking at, where you, uh, comparative to your peers, uh, possibly stand out as an outlier. Now it’s not necessarily bad to be an outlier in a particular area, but it usually isn’t good. Uh, I had a client recently, uh, get one of these that was an outlier, uh, for a total number of, uh, patients, uh, in patient visits. Uh, but he has a very, very busy practice. He’s opened up six days a week, uh, full time where his colleagues or peers are open up three, three and a half days a week, and he works 10 hours a day. And while there is a really good reason, uh, that he is an outlier relative to the visit metric.
Um, it nonetheless indicates, uh, that he is potentially, uh, under scrutiny for post-payment analysis because the payer isn’t aware of the reason he has more visits than, uh, his, his peers. So, uh, when you get one of these, look at, look at it, uh, try to understand what concern they have, uh, and if you need some help interpreting it, call somebody that knows what these things are about and is familiar with a post-payment audit process so that, um, they can help you interpret it, look at your, uh, self internally, look at potential ways to diffuse your profile, um, and, um, you know, mitigate the possibility, um, that you get trapped in a PO, uh, or become a post-payment audit target.
Now, um, when
Payers look at providers, uh, they’re looking at data. Um, so if you consider that what’s different now, uh, than say back in what I like to call the Mercedes eighties, uh, in the answer is computers. Uh, back then payers had no ability to analyze data, to understand or see billing trends that were potentially problematic as a result. They just paid claims, and they really didn’t have any way to efficiently identify who they should do audits on or who they shouldn’t. Um, other than total amounts paid, uh, to a particular practice, but that analysis took so much time and effort. It usually wasn’t worth it with the advent of, um, you know, higher computer processing power, better data, analytical tools, payers have become exceptionally, uh, well-versed in the process of analyzing data in ways that identify providers, that they should probably, uh, subject to post-payment scrutiny.
And some of the things that they tend to look for that you can look for in your own practice and get ahead of them is, um, uh, the first thing is you see, on the screen is evaluation management or ENM utilization as a, as a percentage of the total number of patient visits. Now, some practices do the standard. Uh, we do 12 visits, we do a reeval, we do 12 visits, we do a reeval and they’re banging out, uh, an evaluation management service every time they do it. Now, the larger medical necessity issues of what makes the 12th visit so magical, uh, as a measure of improvement in the answer is nothing but, um, be cautious about, um, your evaluation management utilization, uh, while in some cases, payers will permit in evaluation management for re-evaluation, uh, on audit. Uh, oftentimes they don’t because they don’t see any new decision-making or whatever the point here is.
Is that the more ENMs you bill, uh, as a percentage of your total visits, um, the more likely you are going to get audited if for no other reason that metric, and then once the audit happens, um, you know, it can go a variety of different directions, even if your ENMs are well justified. So you want to be cautious of that as a percentage, uh, something less than 10%, uh, would be probably appropriate. Um, any more, uh, you can usually get a, with a diminished treatment cycles, you’re going to get away with the initial evaluation. Some payers don’t even like to pay for that. Um, and, uh, and after that, um, probably no others. Um, if you are into a four, six week treatment plan, you might have one more, but, uh, as a general rule build the initial one. Um, and if you’re going to do a discharge, Val, um, you know, do it as a separate visit where you don’t treat the patient, the next one is a CMT levels, not with not surprisingly, um, two areas of concern, people that bill 99, 42 all the time are no doubt going to get audited.
Um, but surprisingly people that cluster code and bill 99, 4 1 all the time, either because they’re too chicken to bill a 9 8, 9 4 2, when they’re treating full spine, um, or because they just treat three to four regions all the time, uh, become audit targets simply because most patients don’t present with significant complaints in three to four regions of the spine. And, and, and tell me if you’ve heard this one patient comes in, they tripped over the cat, did a head plan into the wall and they’re next killing them. And they can’t turn their head and they can’t sleep and have difficulty driving, blah, blah, blah. Um, and the doc does a history of present illness on the cervical region, and then ask the magic question, how’s your low back feel? And you know, anybody that’s, uh, middle age or, uh, relatively active might say, oh, it’s sore from time to time.
Ding, ding, ding, ding, ding. And now we’ve got a 9, 8, 9, 4 1 out of what should have been a 9, 8, 9, 4 okays. So, uh, and they drive tend to drive because you’re trained to analyze patient’s entire spine. And I get it, the neck bones connected to the toe bone, and even the insurance company understands that they just don’t pay for it. So be cautious about what I call condition creep. Um, and, and when you avoid that, you’ll get a more normal distribution between 9 8, 9, 4 0 9 8 9 4 1. And even some 9, 8, 9, 4 twos, considering that where a patient has suffered a significant injury that, and that involved the entire spine, let’s say they fell out of a tree. Um, then you could start the cases in 9 8, 9, 4 2, but there’s an expectation that some, one or more regions is going to drop out along the way. Um, I never seen that happen in actual fact.
I take that back once I’ve seen that happen 30 years, uh, in actual clinical documentation, but in reality, it probably does happen. Um, and from a practical perspective, what happens if it starts out that way, the, the, the DC is going to continue to treat all five regions until they’re all resolved, uh, just because that’s what you do. So you want to avoid that. You’re probably looking for a 55 to 45%, 4 0 4 1, um, scenario, couple percents of four to maybe thrown in there, potentially flip, depending on whether you’re, you know, patients are predominantly white collar, blue collar, blue collar, um, patients tend to have more low back problems. Um, in which case it’s pretty easy to justify, uh, three regions, um, white collar people cause it work or computers tend to have more cervical upper thoracic problems. So they’re, they’re your four cases. So be cautious there, um, therapy, uh, for those, uh, that have insurances where, um, a patient is, um, receiving, uh, rehabilitative therapy or manual therapy, um, be cautious about how much direct one-on-one contact, uh, uh, services you bill in a particular day, month, week, whatever, um, carriers love to do.
What’s called impossible day analysis, uh, and where you’re utilizing, uh, chiropractic assistance, whether they’re certified by your state board or states that don’t do that, whether they’re completely unlicensed. Um, as a crazy example, let’s assume you’re one doc and you have 10 rehab assistants out working on the floor. And let’s assume even that the payer doesn’t get annoyed by delegation. Uh, some states don’t permit delegation of procedures like here in Pennsylvania, other states do payers have varying policies, but let’s just assume they’re not concerned about the delegation, but from a pure volume of billing perspective, you have 10 people generating time-based codes all day long, making the, and it’s all built under the DC. So it makes that doc look super human. Trust me, you’re going to get audited. Um, it’s going to gather a lot of attention because mathematically, it doesn’t seem possible for one doc to do all that care.
Um, now it’s not necessarily improper, but what we’re talking about is the risk that you’re going to get audited. So we’re possible. Hopefully you have some associate DCS. You can diffuse your billing amongst the DCS in the practice. And I’m not saying do that arbitrarily, but, you know, assign different docs to supervise the performance of different therapists so that you, you get a more diffused billing profile and it’ll minimize the level of risk you have. Additionally with one-on-one contact services, if you’re billing a one-on-one contact code like 9 7 1 1 0 through 9 7, 5, 4 6, with the exception of the group therapy code 9 7 1 5 0, make sure you’re providing one-on-one contact. Your documentation supports that level of contact, that it was skilled contact, and you identify the person that provided that contact. Uh, otherwise those one-on-one contact services would likely be denied and post-payment review visits per patient. I mentioned a recent CBR where that was the issue.
And look, if you’re a busy practice. Great. Um, I didn’t, I remember years ago, this was probably 20 years ago. Did a provider came up, uh, under this metric, um, because doing the math, uh, given the hours that the doctor was supposedly open, uh, even though he was open more, um, but doing the math on his published hours and the number of visits, he was spending 4.7 seconds per patient. And while I usually don’t travel to doctor’s offices to see what’s going on, I did in this case and sure enough, the staff had to pay and he did manip, only staff had the patient prep, the zoomed into the room, did his adjustment and zoomed right out. I mean, it really was that quick. Now we can all debate on whether that’s an appropriate way to manage patients or whatever. But, um, the simple fact that his volume was what it was, uh, was the basis for his audit.
And of course, once the audit happened, the issue turned, you know, change from, uh, you know, we convinced the payer that the visits actually occurred and then it changed to issues of medical necessity and other things. So, um, um, apologize for that. Um, so just be cautious if you’re a busy practice, again, you have higher post-payment risk, um, number of visits per patient per year. This is a medical necessity audit criteria. Uh, so you need to watch, um, how standardize your care plans are. I’ve seen fraud cases, mostly brought by state farm, um, in a variety of states. Um, some of them in Florida, some in Delaware, you know, all over the place where, um, state companies like state farm and Geico are arguing fraud based upon cookie cutter care. Um, while I realize it allows your practice to be efficient, uh, and you adopt a care model that works, that’s all well and good, make sure your notes and your documents are patient specific, specific, but be very, very cautious.
If you’re dealing with a lot of plans where the patient has a, you get 20 visits a year, be cautious about banging out 20 visits on every case, just because that’s the limit of their benefit. They get 20 visits if they’re medically necessary. So be cautious. Um, you want to get some diversity, but you’re looking the, the average, uh, visit ratio and Medicare is like 5.8. The last time I checked that metric. So understand that, uh, a lot of payers United healthcare and whatnot have diminishing ideas about what is a, an average metric. And if you get a CBR, it’ll tell you, uh, what the metric is, uh, within your peer group and, um, you know, guide yourself accordingly and you may disagree with it, but, um, uh, if you don’t make sure you have well-documented progression, um, outcomes, uh, changes in objective status and whatnot, to demonstrate that whatever care you did was medically necessary and avoid standard durations of care.
I realize it makes life easy, but if being a doctor was easy, I’d probably be one. Um, last slide here, visits per condition. They do track the number of visits by diagnosis code. Make sure you diagnose your problems correctly. Don’t wimp out and go with cervicalgia and, you know, um, uh, joint dysfunction, cervical joint dysfunction. If the cervicalgia, if the neck pain is based upon a cervical radicular, Titus, a disc syndrome, whatever it is, make sure consistent with ICD 10 guidance that you’re diagnosing the condition that is causing the symptom. And because different patients are going to have different conditions causing symptoms, it’s going to create a diagnostic diversity and help you, uh, justify why, okay, this was a cervical radicular Titus with a disc syndrome, and that patient required four weeks of care. Versus this was a simple, uh, you know, uh, myalgia myositis case.
And we got that one done in four or five visits. Okay. Average, average visit frequency. This one is often overlooked. I mean, PDA has been a chiropractic metric of business performance for years. I look at it a little bit different. I look at visit frequency average as a measure of whether the care is likely to be medically necessary or not just like a once every diet, once every chiropractic care probably isn’t gonna work. Um, I’ve been on the once a week diet plan for years, and it’s really not working similarly once a week, once every two weeks, once a month chiropractic treatment, um, is considered appropriate care, um, depending on the patient’s condition, but it’s not going to lead to the restorative outcomes. So payers will look at your visit frequency, and if it falls to below less than one, I would say probably less than one and a half visits per week.
On average, you’re probably looking at, um, being profiled as providing palliative preventive supportive or maintenance care, none of which any commercial payer or Medicare covers, uh, and that could make you an audit target. The last metric is probably an obvious one, the number of services and the total dollars that you bill per visit. Um, if you have a patient with quote, unquote, really good coverage and you’re killing it, um, and every piece of equipment you have in the office is being used on a daily basis, and it takes you more than one CMS 1500 form to they’ll bill a visit. You’ll get less attention from a payer. If you went down and set the SIU investigators desk on fire, um, you need to be very efficient. Don’t do duplicative therapies. Um, you know, don’t unbundle manual therapy for manipulation to lot too much, uh, things that aren’t on here.
See, um, you know, some coding profile, things like, uh, spinal and extremity CMT all the time. All of those things are, are highly, highly audited. Um, and with respect to therapies also consider diffusing the types of therapies that you bill. So if you’re always billing the same thing for every patient, every visit, that’s going to get you a lot of tension because it’s too predictable. And therefore it’s suggestive that in some cases, those therapies may not be medically necessary. So I hope that’s helpful for you. You can do a lot to manage your own post-payment risk by managing your profile and even where your records aren’t perfect. If you can avoid being audited, then that’s never going to become a problem. So take a look at your billing profiles, look at some of those metrics, uh, get them under control. And if you have some difficulty understanding what they mean, uh, give us a call and we’ll help you sort it out. Thanks everybody. And we’ll see you next time. Um, next week, uh, Dr. MarkStudin will be here, uh, for, uh, his presentation. Thanks everybody. Have a great day.