Blog, Chirosecure Live Event January 18, 2022

No Surprise Billing in the Chiropractic Setting

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Hi everyone. This is Sam Collins, your coding and billing expert for chiropractic the HJ Ross company. And of ChiroSecure welcome to the new year. Glad you’re spending some time with me and I wish you the best and say, Hey, we’ve all done pretty well. Considering what’s gone on in the last few years.

Let’s continue that and let’s make sure we understand what’s going on new and what’s changing. One thing I’m always going to be careful of with you is to make sure you would have the right information. I always will go. I’ve been with the correct information, not necessarily affirmation and often you’ll find people who are adamant about a debate often are more interested in being.

Then getting it right. And I want you to think of all the past hyperbole we’ve all dealt with when things change and everyone gets excited, what am I supposed to do? And if I don’t do it, and I’m going to get in a lot of trouble, what I want to help resolve a lot of that for you, because what’s new for 2022.

And I’m sure you’ve heard of it is the no surprises act or the no surprise billing act and what it means to us. And in simplest terms, it simply means making sure that consumers, whether it’s us as consumers or our patients. Aren’t fooled or aren’t given a bill that they were not expecting. So let’s go to the slides and take a look at what’s going on with this new bill, how it’s going to change for us.

And let’s talk about the no surprises act. It’s actually been around for a while. It’s just being implemented this January at the end of the day, the simple answer is it’s protecting patients from unexpected undisclosed medical bills. And I would think most of us have seen or heard a lot of this type of thing.

And of course, I always go back to. The word hyperbole people often exaggerate. Keep in mind. Remember when HIPAA started, how everyone lost their mind. You’ve got to do this. You got to do that. Now. Hip is very important, but it’s about privacy. Does it require you spend tens of thousand dollars to comply?

No. So I always go with something called . And it’s meant to go with what’s the simple solutions shave away the exaggerations. So let’s do that with this no surprises act. This started of course, January 1st of this year. And it’s to make patients or consumers not getting unexpected medical bills.

Think of it. How many times have you heard someone went to a hospital? They go to the hospital. They choose it because it’s an in network hospital. The doctors they’re great. They get this. Then they have a surgery and all of a sudden they get a bill from the anesthesiologist who happened to be out of.

And of course the patient goes, wait a minute, I wouldn’t have chosen this whole, this hospital. If it weren’t in network, how are you giving me this unexpected bill? And what this is doing is protecting us from that. Now, how does that work for us as a small practice provider? It does have some factors for us to consider, but let’s consider it more from who is it affecting the most and that’s going to be our patient.

So it says here people with health insurance or with health insurance or without health insurance, in other words, your cash pay. I want to stop for a second and say to that, don’t you already do that? Do your cash patients ever get a surprise bill? I would think not. That’s something that would disclose right up front.

So I don’t think that’s much of a change for us though. Some people will make you feel differently, or it’s also people with health insurance who receive an item service that’s not covered. So by example, let’s take like American specialty health. If you have an American specialty health patient, generally it doesn’t cover massage or manual therapy.

So what you have to do to collect it from the patient, since it’s a non-covered service, you have to disclose before this. That it’s non-covered and the patient understands it like a Medicare ABN. If you’re familiar with advanced beneficiary notice, it’s a way of notifying the patient of something that’s not covered.

So they’re aware of the costs, but it’s also people who have insurance, but plan to not use it for a portion of that care items. Remember, does a patient always have to use their insurance? No they don’t, but then of course it’s simply disclosing to them what the costs are. So I want you to think in this way, aren’t you probably already doing that, think of it in a chiropractic office.

What are you already doing with every patient? I’m hoping you have a financial agreement that does this. Here’s a starter. Many insurance policies do cover chiropractic care, but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for chiropractic care.

In other words, we’re not guaranteeing anything. Whenever you’ve been to a medical office, do you notice? They say we accept insurance. We don’t accept that as payment in full. And so because of this, your financial agreement likely has some language like. Because of the variance from one insurance policy to another, we require that you, the patient be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office.

Of course, we’ll do our best to bill your insurance. But in other words, what do we do? Disclosing making sure patients are aware of their costs. That’s really all this law is doing. So who has to do this? The provider, we have a duty and we have to remember when you’re in network or out of network.

That does make a difference. If I’m an in network provider, frankly, I don’t find this to be very complicated at all. If you have an American specialty health patient, it’s pretty straight forward. There’s a couple. It’s $10 or you’re with blue cross blue shield. Anytime you’re a network, it’s pretty easy because there’s going to be fixed copays.

And there’s contractual. Write-offs, I’ve seen this before. You have you build out $150 for an exam. The insurance company says it allows 47. And they pay 80% of that. Therefore, the patient’s going to be responsible for a little over $9 or 20% of that. So that’s a pretty easy way of giving information to the patient and they’re likely aware, and let’s face it a lot of times.

That’s why people choose you as a provider, because of course they know exactly what their costs are. For an out of network provider though, it becomes a little bit harder because now we have something we call co-insurance co-pays are easy. It’s fixed, but when you’re out of network, there’s actually nothing.

There’s nothing that’s called a co copay. It’s co-insurance because it’s going to be the amount that wasn’t paid by the insurance. It’s the balance. So there’s no contractual write-off so let’s take that same example. I bill $150 for. When I’m in network, the allowed rate is 47 50 with a 20% amount from the patient.

But what if you’re out of network, you build $150. The patient then still has insurance. And let’s say it covers the same. It covers 47. The difference here is the patient owes the difference. You don’t write it off that other amount, you have to collect it. So in other words, when you’re out of network, if you’re willing to build something, we have to be willing to collect it because there are no contractual write-offs.

In other words, there’s a balance. So what’s important that we do is make patients aware that my fee is 150. Your insurance is going to cover some of it. We can’t guarantee that. And you might even assume, Hey, maybe it’s going to pay $50 of it, but the patient is going to own the balance. Now let’s keep in mind.

I’m talking about a balance you’re all familiar with. What’s called the anti-kickback statute or false claims. Remember you cannot routinely write off balance. It’s part of the reason when you’re in network, you can, because there’s a contract, but when out of network you cannot. So you got to make sure patients understand that difference in price.

And here would be my statement. And it’s just this last bullet. If you are willing to send that bill out, that means you’re willing to collect it. So here’s one of the things to be careful of. Don’t set your fees off of your best paying insurance. As much as we’d like to, let’s say you might have a few insurance companies that pay $300 for a home visit fantasy.

But what in turn, if you have a patient’s insurance that only pays $50 and you’re out of now. That patient now owes you two 50. So it’s something to consider to be somewhere in the middle. So the duty of the provider or the health care facility is to provide what they call a good faith estimate.

In other words, an estimate of charges, it doesn’t necessarily have to be exact, but a good estimate. And it’s about it is a $400 threshold. Yeah. On a single visit. That’s easy because no single visits, probably over $400. That will be it. Maybe won’t have an exam in a lot of x-rays. So I don’t think we run into a problem there, but the whole point is to make sure patients are aware of per visit.

This is likely what your out of pocket is going to be. And think of it from a consumer standpoint, from ours. When we go to the doctor, we hope the same thing. And what I would do is do not over-complicate it. And I put here provide a clear estimate of charges and what’s likely to be out of pocket. I think we’re doing.

I hope we are let your patients know here’s the services we’re providing. Here’s the amount of charges. Here’s the expectation of your insurance. We’re not guaranteeing, but expectation. This would likely be your balance. So when you’re out of network, we have a greater duty to. And networks easy because it’s a set fee, but out of network.

So you might think, is this the way of insurance companies getting me to join? No, it’s a way of being upfront to let patients know what you’re charging. One of the things I’ll tell you my dad’s practice. He did a lot of personal injury and he made sure patients knew because they were very injured in getting that very intense care.

That visit was expensive often over $200. We’ve got to make sure they’re aware of it. Now there’s a value to the 200. So make sure the patients see it and understand the. Who else has a responsibility of this? Obviously we do. But what about the payers? What about the insurance companies? And this is the area that I’m most excited about because this is really more on the insurance companies, in my opinion, because let’s face it.

How do we know what they allow? Have you ever tried this? You call an insurance and you say, do you cover chiropractic? Oh yes, we do. Then how much do you allow for 99? Four oh, or any other code? Oh, we can’t tell. So then in other words, how can we really disclose without doing that? So that’s why we have a duty to tell the patient what our full fee is, but here’s, what’s changing a little bit.

This duty, the insurance company is a few things. Number one, and this is going to be important. They have to verify every provider who’s in. Whether they wish to be in or out of network every 90 days. So fully expect if you’re a network or something, you’re probably going to get some type of notice every 90 days to reaffirm.

You want to be a network because one of the problems that I’m sure you’ve run into this, you drop out of a network and you did so a year ago, but for some strange reason or reasons that the insurance company is lazy, your name still appears. So the patient comes into your office assuming, oh, you’re in network.

And then you bill and you’re out of. The insurance company now has a duty for that. So here’s going to be the, the cool news with this. If an insurance company has listed you as in network and you are not, you now can dispute that. And of course the insurance company will have a duty to pay it.

Now, that’s going to be interesting to see that implemented, but that’s really going to be the issues. So a 90 day to make sure that you’re in or out of network we’re going to, from that much more. And once it’s been affirmed after update that directory within two businesses, And providers who don’t verify they have to pull off.

So these lists should get a lot better. I’ve run into offices over and over with our network where I help them, where they’ve dropped out a plan six, seven months ago. But their name still appears on the list. How lazy is that by an insurance company? So I think this is putting more emphasis to that because how do you choose care when you can’t know what your insurance, what members are, or are not in network or what it means to be out of network?

So part of the law also emphasizes something else. And this to me is maybe the biggest. Insurance companies have to be more transparent about what they are allowing for services. And so you should see more and more online portals like Availity and others that make it accessible for you to know what it plans allow.

Now, I’m going to give you a simple solution to that. You’ve all built insurance before, and let’s face it as much as we think we bill a lot of insurances. We don’t build as many as we. Most often you’re billing, probably five to six, seven insurance companies. What I’d like you to do, start to create a spreadsheet, lists those companies, and then just list your common codes.

I don’t need you to list every code, just the code you bill regularly, and let’s face it again. How many services do you do on a regular basis? Seven or eight manipulation therapies, exams. And what I’d like you to do is go through and gather that data from that plan, what does it allow and pay? So that way you can inform the patient better of what their balance is.

Now, that’s just a good business practice because I want a patient to be able to choose care based on their knowledge of what the costs are going to be. If they’re using insurance, if they’re not using insurance, no big deal. I let them know right up front. That’s pretty straight forward. So here’s what’s happening and take a look here.

This is the Availity portal through blue cross blue shield of Illinois. And there’s a new tool you go to available when you’re available. And when you’re in network, you should be able to plug in a code and it will tell you the fee and that way you can make a good estimate. One, are you way overcharging and or are you undercharging?

But most importantly, the fee that way your patient has full disclosure of what they’re going to pay out of pocket. Let’s remember the back end of this is to make sure the patients are aware of their. The other part of this, that’s cool. Let’s say you’re out of network and this insurance company pays some ridiculous allowance where they say, oh, that’s the usual and customary, which they always like to hide behind.

Now there’s going to be an independent dispute resolution where they won’t be able to hide and say we pay $50 for something that clearly has a usual allowance of say. And so the first thing we’re going to be able to do is dispute with the insurance and if they don’t relent and, or it’s not fair, there’s an independent government agency that will now handle this.

And it’s independent. Now I will highlight it’s going to cost a little money, but when I say a little $25 from us 25 from the insurance, and I would make the patients initiate this because this isn’t an interesting. If you give someone a discount, quote, unquote, they’ll say, oh no, you can’t do that.

But an insurance company can. So we’re going to be able to start to push back on that. My part of this, that I think is the thing that’s going to be most striking. We should have a lot more transparency of what these insurances allow. I would say in the short term, though, gathered data from in your office.

What I do with my network offices, I help them gather that data, get into your files and say, okay, who are the big five insurances? Your. Let’s list your eight most popular codes. What does that plan pay then? What is the other plan pay? So I know what each pays. I know what the patient will. Oh. But you know what I do with that data as well, you’re going to look and go, Ooh, that plan pays a lot better than another.

And if I have a plan that pays better than another, wouldn’t it be smart to market to those patients? Why not? Wouldn’t I want a patient that has a better. Of course. So I want to have a little bit of movement there, so I know what’s going on. So the summary of this is going to be, keep it simple, establish a fair and reasonable fees.

No, that your patients may have to pay the full thing. That’s the estimate or their insurance may pay sun clarify if you are in or out of network with any particular carrier and in, for your patients, when a patient comes in and they’re thinking you’re part of blue cross blue shield, and you’re not be really clear with them and say, Hey, I want to make sure you’re aware.

I am not in your network. And there’s say, but you were on the list. Now we’ve got a dispute resolution that chances are that insurance is going to have to pay better because they did not disclose properly. And that’s what I want. I just want a fair and equitable. I’m not saying we’re always right. And we’re doing the right things.

Quote unquote, we’re attempting to, but I do know the same on the insurance. I want somebody that can oversee that as well. Make sure you disclose your fees to your patients at the time of care. What’s the costs. Let there be no surprises. Don’t have someone going, oh my God, I didn’t know. This costs $300.

They should well know it was 300 because the value was there be clear on their out-of-pocket costs. So when you’re doing your financial agreement, tell them what the cost is going to be. If you’re in network, of course, easy, but if out of network, let them know the full charges, what this comes down to a simple discipline.

So that your patients are not having any problems now, realistically, from a chiropractic standpoint, I don’t think this is going to be as critical because I believe we’ve done this already. Chiropractors are very good about making patients understand fees. And that’s why often we do have some type of cash discounts.

Maybe we’re using a discount medical program, maybe for that matter, you’re doing some type of prepaid plan, but in either case you’re always doing. To disclose, and that’s all we want, make sure that the patient understands their fees. And I would say avoid the hyperbole and look at the simple solution.

So here would be an example. This is a form that we have, we do this for our network members and people have digital coding, but it’s a simple financial agreement. I want to highlight two, two areas that I put arrows to. It says our services may or may be, may not be covered by insurance. Our office and providers are not in network with any insurance.

So when you don’t belong to something, make that clear, we don’t belong to anything. Therefore everything you get towards, your payment from the insurance. Great. But you may owe up to the balance. And so of course, we’re going to provide you with a good faith estimate and maybe you put a list together like this here’s my exam fee, the adjustment fee.

And here’s the total fee. Here’s the expectation of what the insurance is going to pay that way. There’s a disclosure. I would bet. Maybe not quite this detailed, you’re likely, already doing. When it comes to your financial agreements, I’m just saying, make it a little bit tighter or more clear. What about if you are in network with the plan, it is pretty straight forward, but I want to highlight two areas here.

It says, as a member provider of your plan, we will directly bill your insurance and you will be responsible for the copayments at the time of service, as well as it needs a deductible. In other words, straightforward of what it’s going to be because. And of course give them a financial responsibility of the copay or, and or if it’s an excluded service, think of it.

What is this program or what is this law doing? It’s making clear that patients know their fees. Chiropractors are good at that. Do you know that chiropractors are the one profession that don’t have problems with copays? The American physical therapy association did a study last year, where they found that once a patient at a $30 or more copay, they would lose about one third of their patient.

Do you know that wasn’t evident for chiropractic? You know why? I think it is because chiropractors have never fully relied on insurance. It’s an, a. But because of that, we placed the value on the service. And so does the patient and if they’ll pay for it. So now these two forms, again, are pretty straightforward and simple.

If you have our digital coding through rate stray loss, they are in the document. Library actually will be in there later this week. If you attend a seminar with me, they’re included there, or if you’re a network member, of course also. So I’m gonna encourage you to start to get the right information.

Don’t get in the hyperbole and probably start to look at who’s going to help you do that. We offer a service. We call the network with HJRoss, just go right to our website, where it’s a hotline. You can call me, email me, fax me on a daily basis. Some every few months, but we also offer two levels. One is the lower cost where it’s just a question and answer, but more of the platinum or our premium, where I become part of the office in this way, we have a monthly meeting and seminar together, a group seminar, and it provides two continue education seminars per year.

Always know that ChiroSecure, and the HJ Ross company are your partners. We’re here to make sure that your practice thrives. So if you have questions or needing a resources on news or updates, go to our website, HJ Ross company, our phone numbers here. And I’m going to say to all of you, slow down, relax, take a breath, get the right information and move forward to help your patients because that’s what you’re looking to do.

So I’m going to wish you again, a very happy new year and say next week, the guest hosts will be Sherry McAllister, take care of everyone else.