Special Feature


Software Clearinghouse Support Key to Improved Revenue Cycle Management
Special Feature
Written by Dr. Gabe and Sherrie Spruch, All Care Health and Rehabilitation Center   
Tuesday, 23 October 2012 20:42
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ffective billing and claims submission processes and procedures, both during today’s current challenging economy and in better times, have been key to our chiropractic practice’s continuing health and ability to grow. Improved revenue cycle management has positively and directly impacted the level and overall quality of the patient care we deliver, as better accounts receivable yields dollars for reinvestment in state-of-the-art technologies.
 
lockedfilesThe same can be said for our chiropractic practice brethren. In addition to offering a wider range of patient payment options beyond cash and checks, including credit and debit cards and e-payment, increasingly sophisticated and fully useful software solutions are automating once paper-based clinical and business applications while facilitating integration with collection agencies and clearinghouses. 
 
These solutions serve as inexpensive tools that chiropractic practices leverage to more thoroughly capture revenue from existing patients, while also making it easier to accommodate increasing patient volumes. 
 
We formed the All Care Health and Rehabilitation Center here in Jefferson, IN more than 20 years ago, eons when one considers the now archaic paper-based billing and claims processes then commonly in place. Our practice only a scant two years ago began using billing and notes software and clearinghouse services. We’re still modest in size; our staff consisting of Dr. Gabe Spruch and one other physician, and Sherrie Spruch and three other support staff members. We transitioned to our current system after years of enduring painful and time consuming paper-based processes, followed by a period during which an outside billing service handled our billings and claims electronically. 
 
Frankly, the thought of moving billing and claims processing back under our roof was not something we initially were wildly enthusiastic about.
 
But we’re glad we did, and are certain that other chiropractic practices either feel the same or are seriously considering going the same route. The revenue cycle management solution has fully automated our entire suite of clinical and business processes, from scheduling and documentation, to accounting, administration and enterprise management. Our overall practice efficiencies and end-to-end payment management have been markedly improved, as has workflow as it relates to reduced billing and clerical errors, reduced accounts receivable and faster payment posting and book balancing resulting from an auto-remittance feature.
 
Software, by itself, unless used properly and to its full capability, won’t enable chiropractic practices to be as efficient as possible. Built-in analytics tools enable practice administrators to closely examine patient responsibilities like co-payments, deductibles, coinsurance payments and other similar fees. Reviewing these, over time, has enabled us to better identify problem areas and work with patients in addressing the most serious situations for improved revenue flow. 

We electronically sub-mit nearly all—99 percent—of our claims.

 
It’s also critical that solution providers walk physicians and support staff step-by-step, process-by-process to do so. Practices must be aware of each individual insurer’s unique policies and procedures, and learn exactly how to file claims to each. Practices therefore should choose software not only based on its functionality and cost, but also as it relates to a vendor’s ability and willingness to provide strong support before the sale as well as during and after implementation.
 
The best systems don’t only facilitate claims submission; their developers will also hold claims for chiropractic practices for required edits, dramatically reducing insurer rejections, speeding up payments and maximizing revenue flow. Some vendors will also electronically accept remits on a practice’s behalf, so that all the chiropractic office needs to do is download them into the billing software. Here at All Care Health and Rehabilitation, all we need to do is download a remit and the software automatically pulls up the patient’s claim and posts it to the account on the date of service.
 
What a time saver! Other revenue cycle management features built into some software solutions provide practices with all pertinent information relating to individual claims and provide the ability to resubmit claims directly through the vendor’s website for a seven- to 10-day turnaround, depending on the insurer. We electronically submit nearly all—99 percent—of our claims. Because not every insurance company accepts electronic claims, it’s also helpful to choose a software vendor that will ease your practice’s burden by filing paper claims for your practice.
 
As we stated, today’s economic conditions are less than stellar, with high unemployment and frequent changes in employer healthcare coverage. Patients like never before are struggling to meet direct medical costs. Chiropractic practices that offer flexible, consumer-friendly payment options provide patients with increased incentives to make prompt payments, while software solutions from supportive vendors accelerate the revenue cycle through improved billing and claims processes.
 
Combined, these policies, procedures and solutions generate improved revenues and profitability. The increased cash flow enhances a chiropractor’s ability to provide higher quality care with added resources for medical technology investments, and lower patient, physician and staff member stress levels.
 
Dr. Gabe Spruch, with his wife Sherrie Spruch, is the co-founder of All Care Health and Rehabilitation Center, launched in 1990 as All Care Chiropractic. Dr. Spruch is both a chiropractic physician and licensed professional acupuncturist. He and his staff work to help patients achieve better health with proper nutrition, exercise, structural alignment and balanced internal energy. You can visit the website at: http://www.allcarehealthandrehab.com/ or call  (812) 288-7000. His practice uses ZirMed for their revenue cycle management solution. For additional information, visit the website at: http://www.zirmed.com.

Sherrie Spruch, co-founder of All Care Health and Rehabilitation Center with her husband, Dr. Gabe Spruch, serves as the center’s practice manager. In addition to overseeing day-to-day office operations, Sherrie shares with patients her wealth of knowledge about the importance of natural health care. You can visit the website at: http://www.allcarehealthandrehab.com/ or call (812) 288-7000.
 
From Checks to Mobile: Three Simple Methods for an Integrated Payment Processing Strategy for Chiropractors
Special Feature
Written by Matthew Llewlyn   
Tuesday, 23 October 2012 20:03
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hiropractors, like many other healthcare providers, tend to operate individually or in small groups (1-3 providers) with a limited amount of administrative staff to manage cash flow and collect for services rendered. Matt Llewellyn, VP of Healthcare Sales at BillingTree, takes a look at three methods of patient payment processing which chiropractors may use to improve collections and cash flow.
 
mobilebankingThere are distinct challenges in terms of managing cash flow and collecting patient payments for smaller professional practices with limited back-office staff to manage all the administrative processes needed to support the business. 
 
These three optional patient payment processing methods can help practices implement simple procedures to improve operational efficiencies through the use of readily available technologies. The payment options range from the basics of processing paper check payments more efficiently to the more advanced payment options such as SMS and personalized web portals.
 
Method One: ACH – every check counts!
 
Although many people elect to pay bills with debit and credit cards, a significant number of payments are still made by check. If your practice accepts paper checks there is no reason for you to continue the paper process to deposit the funds. Why not convert the check to an electronic deposit? 
 
One easy way to convert the paper payment to an electronic deposit is through the use of a scanner that will convert the check to an Automated Clearing House (ACH) transaction. The check is converted to an electronic file which is then sent through ACH payment-processing gateways. ACH payments processing provides more efficient cash management capabilities and lower costs than traditional paper payments processing. Providers that use ACH processing benefit from an accelerated availability of funds, with cleared funds deposited directly into their accounts.
 
One thing you want to be sure of when converting paper checks to an ACH transaction is that the checks being converted are coded with the correct SEC code. The code used varies based on how the check was received as well as whether the check is from an individual or a business.  
 
Another factor to consider is having the ability to automate check representment when checks do not clear the first time. You will find there are automated processes which will enable you to pre-set times of the month for check representment, choosing times when the patient is more likely to have funds in their account to cover the check.
 
Method Two: Mobile payments are on the rise

By providing the patient with this new payment option your office is expanding the patient preference communication offering.

 
You cannot walk down the street or be in a public place today and not see individuals using smart phones. There is a growing desire for people to interact with others through their smart phone, and patient-to-provider interaction is no exception.
 
Do you provide your patients with a “preferred method of communication” option as part of your registration process (i.e. mail, e-mail, cell phone, etc.)? If you do, it's likely that some will select their cell phone as the option. For those that choose to leverage their cell technology, why not offer them the chance to actually pay their bill with their mobile device?
 
Today, patients can pay their bills through their smart phone, and this manner of payment forms a convenient way for patients who are on the go or who are prone to be more responsive when they are messaged on their mobile device. Technology today enables a patient to establish an e-wallet, secured with the use of a user-defined PIN and command on their phone. Your billing staff can leverage available technology to reduce costs associated with consumer contact, including time sensitive notices and recurring check reminders, as well as the expense of traditional paper billing. 
 
As an added benefit, your office is adapting to the changing environment in which the patient experience is becoming a measured metric in the care cycle.  By providing the patient with this new payment option your office is expanding its patient preference communication offering. 
 
Method Three : Electronic Payment Portals – providing patient access to information online 
 
The Government is working hard to increase the adoption of an Electronic Health Record (EHR) and patient portals. If your office is already offering a portal to your patients, adding web payments functionality is a logical next step. If you already accept web payments then that's great news!  
 
A few things to consider when offering web payment options to your patient are: 
  1. User Friendliness – to make the process as easy as possible for the patient to pay 
  2. Type of payment options – can you only make a single payment or can the web solution accept recurring payments?
  3. Using Personal URLs (PURLs) for patient payment – encourage electronic payments from paper statements and invoices, so customers can quickly pay online.
In summary, there is certainly a shift occurring in patient payment responsibility, wherein the patient will have more out-of-pocket funding for care. In addition, technology is evolving and the way patients prefer to interact is changing in line with this.  
 
The question to be asked and answered is: “Is my practice leveraging available technology which best meets the expectations of my patients, while also improving operational efficiencies and cash flow?”  
 
If the answer is “no” or “I'm not sure,” then consider implementing one or more of the above methods to integrate solutions that will help you answer this question with a resounding “YES”.
 
Matt Llewellyn joined BillingTree in 2012 bringing over 20 years of experience in healthcare and IT. As Vice President of healthcare sales and new business development, Matt is responsible building on the existing success within the vertical and to identify and implement new partner integrations from within the healthcare market. Prior to joining BillingTree Matt held senior leadership roles at multiple organizations including TVP, Channel Strategies for RelayHealth and VP  of Hospital Sales, Western Region, for NDCHealth. You can call at  (602) 443-5914 or email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
 
 
 
Subluxation vs. Disc Herniation
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Special Feature
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Tuesday, 23 October 2012 19:32
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hiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006 as reported by Davis, Brenda and Williams in 2010. This represents 4.12% of the population, considering the 2003 population reported by the Encyclopedia of the Nations. Davis et al. also reported that in the early 1990s chiropractic utilization was 7.7% of the United States’ adults, realizing a net loss of utilization of 3.58% in just a decade. The reasons are many and in spite of the growing interest in the utilization of complementary and alternative medicine (CAM) nationwide, with chiropractic as the largest CAM provider, the numbers are still dwindling. The chiropractic profession must take an honest look at the numbers and realize that it can no longer be "business as usual" or risk that the utilization will continue dwindling until we no longer make the positive impact on society that we currently do. 
 
subluxationvsdischerniationFiore in 2012 reported that accurate diagnosing was critical to the success of the chiropractic profession in order to be credible in the health care community. He also reported that many chiropractors hide behind the definition of chiropractic as the "...art, science and philosophy of locating and correcting nerve interference..." and continued on to say "This allows the chiropractic profession to have great latitude...but does not excuse us from making an incorrect diagnosis." In order for us to understand a spinal related problem or any pain, we must not create a correct hypothesis, we must conclude an accurate diagnosis before we construct a prognosis and treatment plan. According to Frank Zolli, DC, the Dean of the University of Bridgeport College of Chiropractic for over 20 years, "every chiropractic student during their doctoral training learns at the most basic level of training that you must have an accurate diagnosis and then create a prognosis before you treat your patient." Dr. Zolli continued by saying that this is taught in every CCE accredited chiropractic college.
 
With the advent of new and not so new technology, we no longer have to hypothesize or theorize. It's called the MRI and every licensed doctor of chiropractic in the United States has within their scope the ability to refer a patient for an MRI (with the exception of Medicare, as the Federal Government, through their actions and regulations, has much less regard for the well-being of our seniors). Chiropractors have to realize that technology takes away much of the hypothesizing and allows us to conclude with a great degree of certainty an accurate diagnosis: the foundation of the treatment plan. 
 
When we look at disc issues, this gives the chiropractic profession a universal platform to becoming and being considered by medicine to be the "Spinal Primary Care Providers". Back pain, inclusive of disc pathology, is a thorn in the sides of most primary care providers (PCPs) and a diagnosis they universally refer to orthopedic surgeons for lack of a better alternative.Orthopedic surgeons are centered on surgery, with their $225,000+ malpractice costs, and summarily dismiss most non-surgical cases to physical therapists, who in turn render much poorer outcomes, according to Cifuentes et al. in 2011, for back related issues compared to chiropractic care.
 
Cifuentes  concluded that chiropractic care during the  disability episode resulted in:
 
  • 24%   Decrease in disability duration of first episode compared to physical therapy 
  • 250% Decrease in disability duration of first episode compared to medical  physician's care 
  • 5.9%  Decrease in opioid (narcotic) use during maintenance care compared to physical therapy care 
  • 30.3% Decrease in opioid (narcotic) use during maintenance care compared medical  physician's care
  • 19%   Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
  • 43%   Decrease in average weekly cost of medical expenses during disability episode compared to medical  physician's care
 
According to the U.S. Department of Health and Human Services in 2008, there were 490.41 million visits to primary care medical doctors (PCPs) in the United States that year, when almost every United States citizen visited a primary care doctor across multiple health care platforms. The penetration of PCPs nationally is somewhere between 95-100% of the population, where chiropractic is 4.12% of the population. Understanding the penetration and influence PCPs have over the population and the positive "evidence based chiropractic results" that medicine has long asked for, the chiropractic profession is now poised to become the "Spinal Primary Care Providers", with one proviso. 
 
We need to take our place as spine specialists and not just subluxation specialists to conclude accurate diagnoses and converse in a language that is universal and inclusive to both chiropractic and medicine. In order to do that, we need to learn disc and spinal pathology as a beginning.
 
When utilizing MRI, there has to be a criteria or protocol for ordering a scan and then an understanding of the findings. This author has long held that in the presence of a significant radiculopathic or any myelopathic finding an immediate MRI is warranted BEFORE you create a prognosis and treatment plan. In short: don't touch the patient until you know what the diagnosis is. This protocol has been well documented in the literature as evidenced by the Fish, Koboyashi, Chang and Pham, who also concluded that symptomatic radiculopathic findings or central canal stenosis (as found in myelopathies) require MRI for conclusive diagnosis prior to treatment.
 
When interpreting MRIs it is imperative that each doctor be proficient in interpreting their own film. Lurie et al. reported in 2009 that “…the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases,” meaning that general radiologists inaccurately report what is wrong with your patient almost half the time and you are often delivering a "high velocity thrust", known as an adjustment/manipulation, with wrong information. It is here that you start to become the spine specialist and can guide the PCP in their referral pattern based upon your clinical excellence. The "best of the best" read their own MRI images, no differently than the spine surgeons who will not operate unless they have firsthand knowledge that they know is accurate. Chiropractors are no different.
 
When interpreting MRI images it is important to understand accurate nomenclature. The following was reported by Bailey in 2005:
 
Disc Bulge: Synonymous to disc degeneration. 

Author's note: a circumferential degeneration over time evidenced by a thinning of the disc with the nucleus pulposis still within the confines of the annulus. The disc bulge or expansion must cover greater than 50% of the disc circumference and is usually close to 100% of the circumference.
 
Annular Tear: Tear or fissure in the annular fibers, either radially or concentrically. 

Author's note: The outer 1/3 of the annular fibers are innervated by the A, B and C fibers commonly known as the recurrent meningeal nerve and as reported by Lee et al. can cause pain in either annular tears or irritated degenerative discs.

Herniation: Displacement of the disc beyond the limits of the disc space.

Author's note: Tear in the annulus where the nucleus pulposis material goes outside the confines of the nucleus.
 
Focal Herniation: Less than 25% of the disc circumference.

Author's note: Where the herniation covers 25-50% of the disc circumference.
 
Broad Based Herniation: Between 25-50% of the circumference of the disc circumference
.
Author's note: Where the herniation covers 25-50% of the disc circumference.
 
Protrusion Type Herniation: Author's note: Where the base is greater than the apex in any plane.

Extrusion Type Herniation: Author's note: Where the apex is greater than the base in any plane.
 
According to Robert Peyster, MD, DABR-NR Neuroradiologist, Chief of Neuroradiology, State University of New York at Stony Brook, herniations are traumatically induced.
 
McMorland et al. (2010) found that 60% of surgical candidates had successful outcomes with chiropractic as an alternative to many disc surgeries. The evidence shows chiropractic was highly effective for patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. What about the other 40%?
 
Over the last 23 years, Magdy Shady, MD, Neurosurgeon, Neuro Trauma Fellow, has worked with this author to develop a clinical protocol to determine when chiropractic was indicated in a disc herniation patient. If there is room anywhere around the cord or root, then adjusting/manipulation is a clinically indicated first line treatment. In the absence of any room around the cord or disc, then chiropractic, based upon the increase in intrathecal pressure created in the adjustment/manipulation, puts active chiropractic care in the second position after the disc has been reduced. 
 
Over the decades, that protocol has been followed strictly to the benefit of thousands of patients, where surgery was needed only in a small population of those patients and the first line treatment was bed rest, cryotherapy or anti-inflammatory medication managed by the neurosurgeon until chiropractic was indicated via a combination of a follow up clinical evaluation and MRI.
 
Knowing the difference between aggressive chiropractic treatment or waiting a few days or weeks until the swelling has reduced is a result of making an accurate diagnosis, prognosis and treatment plan. That is also the foundation for relationships with PCPs and being part of a health care team involving multiple disciplines where the chiropractor is the "Spinal Primary Care Provider" and coordinator of health care. 
 
The PCPs appreciate the relationship because it relieves them of the spinal-related patients constantly ending up in their offices as though through a "revolving door" because orthopedics and physical therapy are not the solution and often only serve to delay the exacerbations that end up in the PCP's office over and over.
 
Becoming expert in disc pathology and reading MRIs is the first step towards becoming a spine specialist and tapping into the 95-100% of the population cared for by PCPs. Having control over an accurate diagnosis and orchestrating the triaging of the patient puts chiropractic in the epicenter of spinal-related care and relieves the PCPs of what they consider a "burden to their practice." 
 
It can no longer be business as usual and becoming proficient in disc, MRI and spine care does not change how you care for your patient, nor the philosophy with which you practice. There is room in both the subluxation and structural models of practice. This level of clinical excellence simply makes you a better doctor and opens doors to allow you to become part of the health care team in your community and will ultimately increase awareness and utilization of cost-effective chiropractic management of non-surgical spinal conditions. 

References:
  1. Davis, M., Sirovich, B., Weeks, W. (2010).Utilization and Expenditures on Chiropractic Care in the United States from 1997 to 2006. Health Research and Education Trust, 45(3), 748-761.
  2. United States Population (2012), Encyclopedia of the Nations, Retrieved from: http://www.nationsencyclopedia.com/Americas/United-States-POPULATION.html
  3. Fiore, J. (2012). Subluxation vs. Herniation: A New Paradigm for Chiropractic. The American Chiropractor, 34(8), 14-18.
  4. Primary Care Workforce Facts and Stats No. 1, The Number of Practicing Primary Care Physicians in the United States, (2008) U.S. Department of Health and Human Services, Retrieved from: http://www.ahrq.gov/research/pcwork1.htm
  5. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  6. Fish, D., Kobayashi, H., & Pham, Q. (2009). MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. American Journal of Physical Medicine & Rehabilitation, 88(3), 239-246.
  7. Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations. Spine, 34(7), 701-705.
  8. Lee, J. M., Song, J. Y., Baek, M., Jung, H. Y., Kang, H., Han, I. B., Kwon, Y. D., & Shin, D. E. (2011). Interleukin-1β induces angiogenesis and innervation in human intervertebral disc degeneration. Journal of Orthopedic Research, 29(2), 265-269.
  9. Bailey, W. (2005). A practical guide to the application of AJNR guidelines for nomenclature and classification of lumbar disc pathology in Magnetic Resonance Imaging (MRI). Radiology, 12(2), 175-182.
  10. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.
 
Is Transitioning to a Cash-Based Practice Right for You?
Special Feature
Written by Dr. Miles Bodzin & Dr. Ray Foxworth   
Tuesday, 23 October 2012 19:02
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etween our two companies, Cash Practice and ChiroHealthUSA, we hear from hundreds of doctors a month who think they want to transition to an all cash practice. The reasons are varied, but are most commonly related to frustrations in dealing with insurance companies, hearing about or being involved in a recent audit, dwindling reimbursements and increased demand for pre-cert paperwork or documentation.
 
therulebookWe also find there are many misperceptions about going all cash. Such as, going ALL cash means you are finally free to do what you want in making recommendations to all patients about their care. You can opt-out of every network and disregard terms of the PPO agreements. And, the BIG LIE many have heard is if you are all cash, you are immune to all the rules and regulations from your Board of Examiners, all the way up to CMS and the OIG, when it comes to proper  documentation, billing, coding, discounting, state and federal inducement violations and other red tape including HIPAA.    
 
As is usually the case, the truth lies somewhere in the middle. Going all cash or transitioning to a more cash-based practice can be liberating in many ways, but it is not a panacea. If your State Board of Examiners has outlined the minimum standards for documentation, you are still bound by those standards, regardless of who is paying the bill.
 
If you see patients who may be insured, they will expect to be provided with a proper receipt reflecting your diagnosis with the proper ICD-9 codes, the procedures you performed with proper CPT codes and, if the patient submits the receipt to their insurance carrier for consideration, you may certainly expect to receive a request of records to support medical necessity.  And, while you may have been “PAID” by the patient and think you are in the clear 100%, if your record keeping and coding is not up to par, you can probably expect a complaint filed with your board from a patient who may have SWORN they did not intend to send in receipts to the insurance carrier since you are all cash.
 
Now, as soon as we write this, we are going to hear from someone who says, “My attorney says if I have them sign this form that they won’t file, or that they can’t file a claim when they pay cash, I’m in the clear.”  If that is the case, good for you and make sure you have that attorney on retainer because there is NOTHING worse than dealing with a “ticked-off” patient who decides later that they want their insurance company to pay them back and YOUR notes or records are sub-standard. So much for being immune from rules and regulations by going all cash! 
 
Another area where doctors often think going all cash brings them freedom is in making treatment recommendations and offering varied forms of payment plans or pre-paid plans, especially if the patient is paying cash. Once again, while there is some freedom from not being involved in insurance networks, there are other rules and regulations that may come into play. 

In several states, Boards of Examiners have promulgated rules about pre-pay plans and require escrow accounts to be utilized.

 
In several states, Boards of Examiners have promulgated rules about pre-pay plans and require escrow accounts to be utilized.  Why? You can bet it is because of patient complaints related to refunds!  Also, there are some states that consider collecting in advance for health care services to be the “business of insurance” and you must have an insurance license issued by the state.  
 
Finally on this topic, keep in mind that if you are seeing a patient with insurance, even if YOU are out of network, the patient has certain obligations as a policyholder, such as paying the required deductibles and copayments. Be aware that if you, even as an out of network provider, offer pre-payment plans that include any discounts on the patient’s cost-sharing portions, the insurance company may not be liable for any payment or reimbursement back to the patient.  
 
Diversified Isn’t Just a Chiropractic Technique
 
We are seeing that more and more doctors want to become less dependent on insurance. And there are some who want to go 100% cash, but they are not the norm. For most doctors, the smart move is to do what your investment banker might suggest, “Diversify”. Meaning, don’t be 100% anything! Have a good mix of insurance, personal injury, workers’ compensation and build up your cash side of the practice. This will bring you the ultimate in practice stability and peace of mind by not having your practice disappear overnight if all your financial eggs are in one basket. For doctors who were ALL PI or workers’ comp and practiced in states where changes to these payment methods were implemented, ask them what it is like the day AFTER the law changes and PI or workers’ comp vanished.
 
As long as you understand that the transition to a cash-based practice does not make you invisible from regulators or grant you immunity, then we encourage you to consider diversifying your practice to include more cash-based patients and become less dependent on insurance.
 
Transitioning to Cash-Based Practice has MAJOR Benefits Even When the Patient Has NO Insurance Benefits! 
 
There are three major benefits of placing your patients, particularly cash patients, on long-term care plans. The first benefit is you rarely have patients drop out of care because "the pain went away" or "the insurance ran out". Those are the two most common excuses doctors will state as the reason patients drop out of care. And both are completely neutralized when placing a patient on long-term care plans. So you end up with better treatment compliance.

There are three major benefits of placing your patients, particularly cash patients, on long-term care plans.

 
The second benefit is a result of the prior benefit. You get better clinical results, get more referrals and become more profitable as a practice. It is pretty obvious that if your patients are staying on your care plans, they will get better and will be more likely to refer friends and family.  
 
We also need to state that if you are recommending long-term care plans, you better be able to deliver on the promises you make. We are not talking about just providing "pain relief" type care for a longer period of time.  
 
Let's be real. If you want to deliver on the promise of wellness, you better be able to demonstrate improvements in the patient's well-being. There are some great tools and resources available for doing just that.
 
When recommending long-term care plans, obviously there will be a fee for your services. It is crucial that the way you collect the fees for your care plan is setup correctly. We should start by stating what NOT to do. The idea of offering a plan of care where the end goal for all patients is to prepay for the program (i.e. prepay for a year of care) is not recommended.  Why? The challenge is, prepaying for anything (outside of chiropractic) is not the norm for people and, as noted before, could be considered the business of insurance in some states.
 
People are used to "financing" everything these days.  Look at how TV commercials promote a car.  Do they advertise the price of the car?  No, they tell you the lowest monthly lease payment available.  They do that because they know that the majority of people make a purchase decision with the "monthly payment" in mind rather than the total price.
 
So, offering your patients a long-term care plan that offers payment options is what we recommend.  By offering options, the patient will pick what works best for them. The options are monthly payments, a larger down payment with smaller monthly payments and a prepayment for the folks that want to choose that option where it is legal. We find that most people choose one of the first two options.
 
The last thing about collecting the fees for these plans is to consider using an auto-debit program to collect these payments.  Our experience has shown that the more often people think about the money you are charging, the more likely they will stop care. We have a policy in place to remove every situation we can that reminds them of the money.  So, no statements are mailed.  No third-party financing (i.e. Care Credit or similar plans). We securely keep their credit card or bank account information on file in a PCI compliant program and run the payments on the agreed upon date. This is no different than having a routine to submit claims every Tuesday or on the 1st and 15th. With a proper auto-debit system, it can be BETTER than insurance since there is NO waiting for reimbursement or claims rejections!
 
The bottom line on transitioning to a more cash-based practice is to do it for the right reasons. We encourage all of our clients, even those who choose to go 100% cash, to remember that regardless of the payer type, you should document correctly, code correctly, bill correctly and, if you discount or offer payment plans, make sure you are handling those correctly and start practicing with more peace of mind.   
 
Dr. Bodzin is the Founder and CEO of Cash Practice Inc, a web-based company that provides The 4-Step Process for Reducing Your Dependence on Insurance and New Patients.The Wellness Score, Cash Plan Calculator, Auto-Debit, and Drip-Education Email Systems give the practicing chiopractor tools for implementing the four steps. Dr. Bodzin speaks internationally on running a cash-based practice for Associations, Parker Seminars, Philosophy Groups and for many of the coaching companies. Dr. Bodzin can be reached at 1-877-343-8950, This e-mail address is being protected from spambots. You need JavaScript enabled to view it or by visiting www.CashPractice.com.

Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as  president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a  Fellow of the International College of Chiropractic. He founded ConservaCareCorp, the first chiropractic network selected by the State of Mississippi to serve over 195K covered lives in the State Health Plan. You can contact Dr. Foxworth at 1-888-719-9990, This e-mail address is being protected from spambots. You need JavaScript enabled to view it or visit the ChiroHealthUSA website at www.chirohealthusa.com
 
A Dash of Persistence with a Touch of Honey: A Winning Combination
Special Feature
Written by Kathy Mills Chang, MCS-P   
Tuesday, 23 October 2012 18:24
M
ore often than not, doctors decide about insurance participation based on the horror stories they hear from their friends. It's not unusual for both new and seasoned practitioners to throw up their hands at the prospect of dealing with insurance companies on behalf of their patients. More doctors are also concocting ways to skirt working with Medicare. None of this is necessary. Insurance coverage is a treasured commodity that patients feel compelled to use because of the premiums they pay. A typical practice working within the boundaries of compliance and proper documentation and billing should have no problem working with third-party payers. To cultivate a healthy doctor-carrier relationship, focus on these five areas:yeswecan
  • Ensure You are Properly Credentialed
  • Understand the Expectations and Limitations
  • Know the Medical Review Policy
  • Bill and Code Correctly
  • Firmly Follow Up
Ensure You are Properly Credentialed
 
Every carrier has rules about who does what to whom and who gets the $5, as they say. There are two kinds of relationships possible with a typical carrier: a participating or a non-participating agreement. This is delineated by the rules associated with the contract signed. Medicare, however, is a different animal: Whether participating or non-participating, you must be registered with Medicare to see any Medicare patients. That means you have applied for provider status and are legally allowed to see Medicare patients. Chiropractors have an extra layer of regulation, in that if a chiropractic manipulative treatment (CMT) code is provided, you must be able to bill it, and without being registered with Medicare, participating or not, you can’t bill without a Medicare number. And yes, we are all aware of the nightmare getting registered with a carrier, and Medicare in particular, can be. Here is a story related by KMC University Medicare Reimbursement Specialist Naomi Chance, CPC about a recent experience she was involved in:
 
“It was in the summer of 2011 when a young doctor contacted me about the numerous and complicated problems he was having getting his Medicare Enrollment Applications approved. He had completed every single form required, submitted all sorts of documentation, crossed every “T,” and dotted every “I.” Still, the “Medicare Development Letters” kept coming. He documented tens of calls to his MAC carrier to inquire about all the delays. He asked all the right questions, and pleaded for their guidance and direction. Then he would wait and wait and wait. Every single time, no matter what he did, no matter how many times he reapplied, or how many times he called, wrote, faxed and yelled, his Medicare applications continued to be “DENIED … pending development.”
 
“Development of what?,” he cried.  He did what they asked, but it was never enough. He made corrections to the applications as they instructed him to, yet it was still never right. He was repeatedly given conflicting information by every “expert” he spoke with. One Medicare Analyst would tell him to do something one way, and yet another Analyst would tell him to do it another way. When it seemed like he should just give-up and give-in to Medicare, a friend referred him to us for assistance.
 
Time was running out fast because Medicare’s timely filing limit is one year. Any claims submitted for dates of service after that one year mark would deny and it was going to cost this young doctor thousands upon thousands of dollars. He felt certain he was never going to be reimbursed for all of that patient care and work! The long story made short is, that once we evaluated everything, it was clear that “action steps” would be necessary to get this young doctor’s Medicare Enrollment Applications approved, and the $125,000 in pending claims processed and paid.
 
We went to work fast, gathering all of the facts, data and key information, and knew exactly what had to be done. It took a lot of work, but the end result was HUGE for this doctor. Compliance was in and every one of his $125,000 worth of claims was paid.”
 
The moral of this story was that it nearly took a mountain to be moved to make the carrier responsible for their role in holding up the enrollment of this doctor. But the mountain WAS moved, and the outcome was favorable.  Don’t give up!

Understand the Expectations and Limitations
 
Every carrier will not have a fee schedule that pays what you believe your value to be, or the value of the care you’re delivering. Insurance participation is a very personal decision, made for a variety of reasons. Agreeing to accept a sub-standard fee schedule may work for you because it serves as a marketing arm for your business. Complete understanding of the difference between what the carrier feels is medically necessary, and therefore payable, and what you think they should pay for, helps manage your expectations. Being available as a participant on a plan may open the door to patients who would not otherwise come see you. This open door allows you to explain chiropractic care, the differences between “medically necessary” and “clinically appropriate” care, and who pays for which, AND allows them to know you and make a decision about you becoming their doctor. Having access to this open door may also come with limitations: lower fee schedules, contractual rules and obligations you don’t like, and other penny ante complications of working with third-party payers. That’s why it’s a personal decision. Do the following to mitigate problems later:
  • Read the contract before you sign it! Know if you are agreeing to things against your principles or methodology of treatment. Know if these agreements will affect the processes in your practice.
  • Acknowledge that insurance was not meant to pay for everything. Give the patient the simple fact at the beginning of care:  “Great news Mrs. Jones! Your carrier will contribute toward your financial responsibility in the office! Isn’t that great!” And know this: No matter how much that contribution is, it’s great. If you own it, your patient will too. 
  • Have systems and payment plans in place to help make care affordable for your patients when it is their turn to pay. Utilize a Discount Medical Plan Organization (DMPO) like ChiroHealthUSA to offer legal, network-based discounts. Help your patient understand the insurance card is not a Visa or MasterCard! 
Know the Medical Review Policy
 

It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill.

Whether you choose to work with insurance carriers as a participating doctor or not, nearly every service covered by the carrier is likely to have a medical review policy. This policy outlines the expectation of coverage, the types and descriptions of covered diagnoses, and will summarize what the carrier assumes you are doing if you are billing that service or code. For example, a contract with BCBS of Texas states that massage is a covered service. However, if the patient is receiving 97124, Massage Therapy or 97140, Manual Therapy, the doctor may not delegate that to a CA or other provider working under the DC. It is expected that the DC provides the hands-on service.  Even though the scope of practice in the state of Texas allows for delegation, the contract signed by the provider supersedes that. What if you are not a participating provider? The rules still apply! They state that the DC must always provide the service to be paid for that muscle work. Be sure you know your medical review policy for any carrier you do business with. These simple steps will help you stay ahead of the game: 
  • Create a spreadsheet and include a list of every carrier you do business with. Identify whether you are participating or not. 
  • Pinpoint each major code or code set that you use. Some carriers categorize all physical therapy procedures together, for example, while others list them by individual code.
  • Find the medical review policy on each carrier’s website for each code or code set that you use. Note any special rules or particular issues that may apply to the service as you rendered it, such as by delegation. Remedy any outpoints that are identified, and write internal policy to keep from crossing the line. 
Bill and Code Correctly
 
When scouring the Medical Review policy for the most typical services you render, pay close attention to billing and coding guidelines that are particular to that carrier. Although it doesn’t make sense, some carriers follow their own set of rules that are contrary to national coding principles.  Some carriers still inexplicably require the “51” modifier on the Extraspinal Manipulation code, 98943. This coding policy is outdated and incorrect, and efforts are underway to get such things updated. Meanwhile, however, whether you agree with the policy or not, if you don’t use a “51’ modifier when billing 98943, you simply won’t be paid. Other rules are easier to follow. It’s easy to stay abreast of correct coding standards by connecting with the American Chiropractic Association or other coding consulting groups. It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill. Keep these tips in mind:
  • Update your coding manual annually. Note in your compliance manual every year that you have updated your coding knowledge and applied appropriate changes.
  • Make proper coding and billing a “family affair”. Educate and support key team members in learning and staying on top of coding and billing rules and changes. Compliance rules dictate that annual training is documented for all billing and coding personnel and that includes the doctor. 
  • Know that you DON’T know.  You were not anointed a coding or billing Queen or King when you received your Chiropractic Diploma. Keep the skids greased between your office and carriers by aligning with trusted advisors who can assist you with keeping your coding and billing on track and compliant. 
Firmly Follow Up
 
Once you’ve ensured that all the insurance relations tips noted above have been completed, and you’ve billed your appropriate services to a carrier for payment, we want your teeth to come out.  Rules and regulations apply to carriers as much as they do providers. When a clean and correct claim is presented for payment, it must be adjudicated within a set number of days. This includes payment OR pending OR denial. Know what your state insurance commissioner has to say about carrier responsibilities for claim processing. Once you know this, set up your internal system of follow up to flag unpaid claims at the appropriate time and get on the phone! Forget tracers! That’s so 1983.  Pick up the phone or get online and find out why your bill isn’t paid. And be ruthless until you get your answer. You have every right to fight on your patient’s behalf for payment of your claim. Internal accounts receivable systems that are worked, tracked and managed will ensure that you never miss timely filing deadlines and every cent that is yours will be on its way to your bank account, post haste.  Try these tips for a smooth process:
  • Set aside dedicated follow up time weekly for unpaid claims from the aging report, and for responding to denials and other reactive items that come in the mail. This often neglected area is usually the culprit in erratic cash flow.
  • Pearson's Law states: That which is measured improves and that which is measured and reported improves exponentially. Reimbursement department team members should have metrics that are reported weekly and monthly that include number of outbound calls, dollar amounts of resubmitted claims, and other important data that helps the doctor or practice management see the follow up work being done. 
  • Be merciless in your pursuit of payment. Go to the supervisor’s supervisor’s boss’s manager if you have to. Use the insurance commissioner. Drag in the employer’s HR department or Ombudsman when you have to. Be an advocate for your patient and be sure you collect what you deserve.
Playing in the insurance sandbox is usually a “win” for chiropractic practices. Whether providing access to more patients who would not otherwise come in if they had to pay out of pocket, or providing a way to be paid what’s reasonable and customary for your services, insurance participation can enhance the business of your practice. You may choose to fully participate in all plans, to selectively identify those with whom you want to interact, or to provide a way for patients to pay you and then be reimbursed. Regardless of your decision, if you decide to work with insurance, do it with your whole heart and soul, and it will be a win-win situation for all parties involved.
 
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at (855) TEAM KMC or This e-mail address is being protected from spambots. You need JavaScript enabled to view it
 
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