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Hello everyone, this is Michael Miscoe with Miscoe Health Law with this week’s installment. Of Cairo secures growth without risk podcast presentation. And today we’re going to talk about as I do at the beginning of every year what happens for patients because it’s a new year with respect to whether they have new benefits or not.
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And the scenario is, is a patient gets, and I use air quotes, gets a certain number of visits every year under their benefit plan. And in reality, they don’t get those as a matter of right. They get them if they’re medically necessary, but many practices go through and they’ll, they’ll treat a patient and when their visits are exhausted, then they move them to cash or the patient disappears.
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And then on January 1st, when they have a new bank of visits, the patient comes in and and the practice starts billing again. And it is a very, very obvious pattern that payers occasionally pick on in postpayment review. And it is almost impossible to justify unless you can establish in your documentation that the That the, that the patient fell put in a star on the Christmas tree or shovel and snow or something, but you know, without a predicate accident causing a new or recurrent injury, you really don’t have justification to start a new.
Air quote medically necessary plan of care. So just because it’s the new year doesn’t and you have a new bank of business to pull from. Remember, the rules about medical necessity still apply and that requires under most payer standards, the patient to present with a air quote significant health problem causing significant functional deficit for which treatment in the area of complaint and functional deficit is expected to result in objective, positive.
Significant measurable improvement in a reasonable and predictable period of time in the care has to be the most cost effective in the least costly setting and that translates to a bucket full of documentation, even assuming you have a patient that has had suffered a significant injury. And for that reason, and because of that documentation burden, many providers elect to just.
Treat the patient palliatively, supportively and so on, such that it’s not covered and they do cash. If you’re not in that camp yet, and you want to build their insurance, just understand those are all the predicate facts that have to exist. And then the argument has to be sealed. With appropriate documentation, objective, measurable goals, all that stuff that, that most EMR programs just don’t do so for that reason, be cautious and you know, when your patients come in and say, Oh, I got.
You know, 20, 20 new visits. That’s great, but we can only use them if they’re medically necessary. And you need to start explaining to your, your patients what that means. So they don’t present with unrealistic expectations requiring you to bill for services that aren’t truly covered that you will only have to pay back later in post payment audit.
Yeah. From a profiling perspective, I, I touched on this briefly, but it is very obvious when they see a patient who they have no billings for a number of months and then all of a sudden at the beginning of the year you know, visits start getting built now, if it’s truly a patient that doesn’t have a significant health problem, whatnot, they’re probably coming, you know, on a.
Non optimal schedule, meaning something less than 3 times a week because they don’t need to which is also an indicator that they don’t. Need in the medically necessary context. The care that’s being provided. I don’t want to suggest that they don’t need it at all. The care is no doubt clinically appropriate, but it’s not medically necessary as that term is defined by insurance carriers.
And so understand medical necessity has two components. The circumstances, you know, they’re looking for a significant injury, significant health problems and get functional deficit. And it has to be something that’s measured. So outcome assessments you know, rating severity of objective problems that you intend to fix with treatment evidence as treatment goes along that, that the status of those problems is changing for the better.
And and then a discharge, you know, the other profiling thing is that if a patient gets 15 visits, you just assume that 15 visits are medically necessary. You burn those up and then and then move the patient to cash. That’s also really obvious when every patient you have gets taken to policy limits as far as covered services on the presumption that clinical necessity or clinically appropriate equals medical necessity, which it doesn’t.
And and in those scenarios, when when payers catch you. When they run data analytics, you know, it, it presents an almost insurmountable argument to our experts, clinical experts, you know, where we’re trying to save visits. Okay, we’re not going to argue that all the cares medically necessary. It’s never going to happen, you know, and we’re lucky if we can save 20 percent of them by digging out facts in the record.
So. If you are going to start and use those visits, you know, remember the qualifier is you need a significant mechanism of trauma, functional deficit, objective measurable goals, get in, do your thing and get out if you save visits for an accident later in the year. That’s great. You don’t want to try to burn through all their visits in one shot.
Remember, pigs get fat, hogs get slaughtered. So, you know, do what you got to do. Stabilize the patient condition, preserve visits for later and don’t build a profile of always burning through all of their approved visits, especially starting at the beginning of the year. Educate your patients.
They need to understand the limitations of their own coverage. So they’re not putting you in a position where you have to compromise yourself and create post payment liability for yourself because. It will come back to Ruth sooner or later, depending on on how bad your profile looks. So, you know, take those things to heart.
I certainly don’t want you coming across my desk with a post payment refund demand where we really don’t have great arguments to defend it. So, keep those things in mind. Happy New Year everyone and we’ll see you next time.
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