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Hey, greetings to my friends and colleagues. Welcome to 2025. Happy to be with you. I’m glad you’re spending some time with us. Thank you to ChiroSecure. But let’s jump into it. What is going to go on for 2025? What do I have to be prepared for? What am I getting ready to do? What’s changing? And what I’ll say is, let’s get ready.
Let’s be proactive, not reactive, as we often also do. So let’s go to the slides. Let’s talk about, are you ready for 2025? Remember, H. J. Ross Company, we’re here to help you. We do have our seminars coming up later this month at the end of the month, but I want to make sure to give you at least a preview of information that’s going to be out there so that’s not always about just a seminar.
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It’s part of the reason we do this. Let’s talk about being prepared for 2025. And again, I want it to be more
And what I want you to start to think first of, and this is something you and or staff can do, start checking to make sure what are the common plans and what if any updates are occurring. For the most part, plans actually don’t update a lot right at first of the year as far as changes. Generally, that’s going to be often in March, July, September, but it could be first of the year.
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But what I do know that’s going to change, of course, is check to make sure what’s going on with planned deductibles. That is always going to be updated at first of the year. Check to make sure that there wasn’t any increase. By example, Medicare did increase their deductible to 257. Now that’s a 17 increase.
So it’s not Oh my God, it’s not even 10%, but it’s still an amount, that we have to be aware of to make sure patients know they’re paying that out of pocket. Here’s a quick trip, a trick. Let the medical doctors take care of that deductible. Meaning, let some claims get in from the medical side, unless they’ve been no place else, let it meet there.
That way, you’ll get paid without having to chase the patient. But nonetheless, check deductibles. What’s going on for 2025? Realize a lot of this can be done online now. You no longer have to make the call. So go online through the portals, check it out, whether you’re using Avaliti or something similar.
But here’s something to keep in mind. A lot of plans have rollovers. When a person is sick towards the end of the year, let’s say they have a 1, 000 deductible. They go see the doctor in November, December, they pay that deductible. Then they’re continuing to see the doctor into January. All of a sudden, a new deductible pops up.
Realize most policies will have a rollover for people who have utilized the deductible towards the last quarter. So that’s something to check on to make sure if it does happen. I’m not guaranteeing that, but a lot of plans may have it. And that certainly can be helpful for a lot of your patients and give them greater access, of course.
The other thing of course to check is just what about any coverage changes? As many of you are aware, a lot of the plans with UnitedHealthcare and Humana for Medicare Advantage now require pre authorization. What’s interesting, it’s some plans, not all. So you want to check to make sure, is there any coverage changes?
Did they change their chiropractic benefits in any way? Did they combine it with anything else? Is it combined with physical therapy? What we want to do is make sure when a patient comes in, we know what’s going to be covered or not covered. to let the patient know what’s going to be out of pocket, what’s going to be their benefit.
Realize within that though, keep in mind, what about a plan that requires pre authorization? Do please ask. I’ve run into a bit of this recently, particularly some plans on the East Coast, but also in Pacific Northwest, where plans are now saying, oh, we’re requiring pre authorization. Now pre authorization is something we’re not typically used to, and while most plans don’t have it, I don’t want to be caught with sending a claim going, Oh, you didn’t get it preauthorized.
Now realize a lot of people will think if I didn’t get it preauthorized, can I get retro authorization? Possibly, but not typically. Do not depend on a retro. Make sure you’re well aware what the coverages are. And keep in mind, what do plans allow? Remember for chiropractic, When you’re billing insurance, what is it going to cover?
Neuromusculoskeletal conditions. If you’re treating someone for a non neuromusculoskeletal condition, it may not be covered. Now, if it’s a secondary or tertiary complaint or issue, probably okay, as long as there is a primary code. Do keep in mind, if you have not updated your diagnosis list, to make sure, am I using codes that are allowed?
Please make sure, because realize there are some codes that can’t be used together. By example, I had an office right at end of the year that was billing out a sprain, but also billing a lumbar disc. And interestingly, those two codes, if you use them together, will not be covered. If you’re going to code disc with a sprain for the low back, you cannot.
You have to pick one or the other. Obviously, I’d pick the disc. Here’s another one. What if you’re coding? Pain, like neck pain with disc. Those aren’t allowed together. Those are called diagnosis excludes. So if you’re not used to understanding that, certainly something to start look up on. Or if you’ve attended a seminar with me, certainly we’ve given you a list or a network member, but what’s also to be prepared for in 2025.
Obviously, what’s going on with fee schedules, and I’m going to say for your common CPT codes, I don’t care about things we don’t do. I care about the things we do. So what are the common codes you build? I’d say for most chiros, probably 8 to 10 E& M codes, manipulation, probably a handful of therapies, maybe x rays, check to make sure what is updated for Medicare rates for those.
You’re thinking why do I care about Medicare rates? Medicare does set the tone, particularly for a lot of plans when it comes to the VA. When it comes to work comp or personal injury in some states, we want to check to make sure what is updated. Realize for Medicare, you’re going to find something interesting because of relative value units and their increase this year in some areas, you’re going to find that though Medicare said they reduced prices, you’re going to find in some areas, it might be a little higher because of relative values.
So it’s something to keep in mind is what should I be charging? Have you really gone through to see? What should be a charge? For example, a therapy compared to what my manipulation charge is. By example, the relative value for massage, 97124, is approximately 10 percent higher than CMT, 98940 anyway.
But I often will see an office bill 50 for a 98940, but then they’re massaged, they’re billing at 30. Why are you billing a code at about 20 percent less when it should be 10 percent higher? Have you really looked through to make sure, am I using the right common fees based on relative values? And setting up what fits for your area.
Now you might say Sam, I don’t care about that because I bill through ASH. Those rates of course probably have not updated. You’re probably right. In fact, you’ll find for those of us that are billing through Optum, ASH, or many of these managed care, my goodness, they haven’t raised rates. 15, 20 years.
How do they expect us to keep open? Just higher volume? At some point that goes out. But what I’m getting to is if you’re in ASH, how many of you have requested at the beginning of the year a raise to your fee schedule with some reasons why? Your cost of living, so forth. If you don’t ask, you won’t get it.
Now, I’m not going to say all plans will, and I will tell you ASH is more likely, some others a little less, but depends on your viability, how much you’re needed, and you do have to make a decision. A preparedness is looking, going, is it worth it to me? I just had a call with an office this morning that they’re getting paid 21 for an adjustment.
out of Aetna. And I asked them, I said that’s not even Medicare. That’s almost, probably about, ooh, almost 50 percent below Medicare rates. Not quite, but close. Can you survive on that? Is it worth it? What if you change that patient to a cash patient and your cash rate is 40 or 50? It really means you need to see two and a half times more people under that Aetna just to break even for a cash.
That’s a lot of extra work. You’ve got to start to really think about where’s my practice moving towards and what am I doing to set myself up based on some of these, which means some plans we don’t accept. You ever notice when you go to a medical office, they don’t say they accept everything. They accept some things, but I want you to look and to note, based on these fee schedules, is it viable for me to remain part of this thing?
Or is your office more of the 99 cent store of PowerPractor? Nothing wrong with that, but volume has to be high. Which means we do have to understand our finances. What are you doing for this year when it comes to your financial agreements? Have you updated anything? Have you made sure that people understand what they’re paying?
Remember the No Surprise Act is what’s going on. We’ve got to make patients aware. What services are covered versus non covered? If it’s non covered, what’s the price? If it’s covered, what is it? Make sure that you’ve got a good setup so you can really start to look and go, is this reasonable? You’ve got to run a business.
Remember, this is your time. To put your practice into, if you will, the shark tank to see whether or not, how much does it cost me to do this? How much am I getting paid? Does it make any more sense for me to remain in some of these things? Maybe not. Because what about cash and prepay? What can I do with a cash discount?
Some states are better. Minnesota, California allow a little more leeway, but what can I do for cash? If it’s 5 to 15%, Is that still going to be far better and will that make more access to people? Or what about doing prepaid plans? I think that’s certainly going to be something that you want to look at to add as a way for a person to come in.
Have you ever thought of, my goodness, that’s how the joint works. It’s a popular place. Why wouldn’t I utilize that a little bit? So I want you to start thinking about a business plan to do that. Now, one other thing here, and I pointed out, is assignment of benefits. Realize, an assignment of benefits should be something that you’re updating yearly.
I will tell you by example, the VA, Medicare, they want a new one every year. Have something new for the year when someone comes in. Just have them sign a new one, date it. That way, when you put signature on file, there’s something there. Because remember, Without an assignment of benefits, who gets the check?
The patient. So I don’t want the patients getting the check unless they’ve already paid me in full. So we’ve really got to start to look at making sure are we prepared for this to be financially viable for us to be a good year. And the last thing I’ll point out though is just simple compliance things.
Have you looked at your privacy notice? Is there anything that you need to update to it? Is there ways that you’re contacting people? There’s nothing wrong with all those things. They have to be disclosed. By example, if you’re going to make phone calls to remind people about appointments, nothing wrong with that.
Just make them aware that you are going to leave a message or send a text and they give a okay to do or if you’re changing anything, it is time to take a look at all the people you deal with. Do you have proper business associate agreements on file with people? Are they following under HIPAA? Is your program following HIPAA protocols?
Meaning if you’re doing documentation, I can’t assume that it would not, but it’s worth asking. What about emails? Can you use your regular email for, communication with a patient if it’s non secured? The answer is generally no, which means don’t use the free Google Gmails and that type, but the ones that you pay for, which we know are private.
What about your consents? Do you have a current consent form for the patient? What if they came in two years ago, and you’re thinking, oh, that one works. No, get one current. What do you talk to them about what’s covered versus non covered? Okay, make sure they’re aware of that. What about cash and prepays if you’re doing that?
What’s my compliance per my state? By example, in Atlanta, or I shouldn’t say Atlanta, in Georgia, you can do prepays. But you know what they require? A 12 point font. Or in Texas, they require that you make sure the patient can make it cancelable. And if you cancel, they just get refunded. None of that’s very complicated, but we want to make sure I have it in place to continue to have success.
And then ultimately, it’s about what you’re documenting, and frankly, I don’t care whether you’re doing cash, insurance, or otherwise. You’ve got to remember whether it’s the board looking at you, or it’s an insurance. If it’s not written down, it didn’t happen. So please take a moment to go through your files.
It’s something I do with our network members quite a bit, and if you’re a network member with me, we haven’t time to do that. But does your CMT match the diagnosis? and the regions manipulated. I have offices that often will adjust full spine. There’s nothing wrong with that. In fact, I’d say many types of techniques do that.
However, what if your diagnosis is only cervical? Would it be appropriate to build a full spine code for adjustment? No. Only a 98940. So make sure that matches. And then your therapies, of course. If you’re doing therapies, great. Are you documenting where was it done? How long was it done? What was the style?
In other words, I want it written down in a way that someone could reasonably look and go, Oh, yeah. That’s there. And please make sure there’s time. One thing that chiropractors really miss out on, and this is something I see over and over because I’m part of the Optum Health Coding and Reimbursement Committee, the number one thing chiropractors run into problems when they’re audited is not having time documented properly.
And that even applies to E& M codes. Remember E& M codes now do allow time. to be a major factor in choice. Now be careful. I don’t want you to say, Oh, I ever spent an hour with every patient. It should still be based on a little bit of a triage and severity, but does it document properly? If you’re doing an E& M of a 99203, does it meet it?
What are the minimum standards? The minimum would be for medical decision making, at least two areas of complaint, trauma, and probably some other outside. Services such as x rays or MRIs, things of that nature. Or it could be that you spent 30 minutes. Either way, it has to be there. What I want you to do is to start thinking of, let’s get my office ready for 2025 to have a very successful year because there’s a lot of things to traverse through that you’re going to start to put them in place now, not later.
Now, if you’re a network member with me, that’s what we do. If you’re not, attend a seminar, join our network where I can help you one on one and do all that. Because have you ever thought of, has someone really looked at, what is my fee schedule? Does it make sense? Am I documenting properly? Do I have the right resources?
We’re here for that for all of you and I wish you the best in 2025. See you again, my friends.
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