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Greetings! How are you, everybody? Looking forward to having some time with you to keep you updated, because, of course, it’s 1st of September, which means time for some changes. One quick note I’m going to probably talk about it in about a month or so, but certainly we have some seminars coming.
Remember, what changes October 1st? Diagnosis codes. This year there is going to be some changes to DISC and tendosynovitis, so we’ll be getting into that. But I want to talk about what’s changing right now. That’s what we’re going to go through today. You probably, some of you may have gotten it. You may not have I put everything out to everyone, our members, of course, and I think even Dynamic Chiropractic has put out something, but probably you receive some type of indication that, oh, UnitedHealthcare, OptumHealth, Even Umana is now requiring pre authorization and beginning September 1st.
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So technically, I guess Saturday or maybe that was Sunday, needless to say, what does this really mean? I think this is where I want to end some confusion. One thing to be careful, there’s nothing wrong with obviously getting on the internet. You’re going to find it this way, but always make sure you’re getting to a trusted source because I’m sure you’re pretty familiar.
When you Google is going to bring up lots of potential information, but is that information accurate? Is it information that is actually pertinent and does it have all the full understanding? And always remember who the author is. Are they trying to sell you something or do something? So I was a little bit careful, but that’s why we do this program.
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And thank you to ChiroSecure for that as well. Let’s talk about what’s going on, what’s happening September 1st, or what has happened September 1st with United, Optum, and Umana. So let’s go and go to the slides. Let’s get into it. Let’s look at these three major carriers. Now, obviously these are some of the largest healthcare carriers in the world.
in the United States covers a lot of people and when they all of a sudden say, hey, beginning of September 1st, you have to have pre authorization. I think there was a lot of panic. I know I had people clamoring, what’s going on? And I’m like, Oh, okay, hold on, slow down. Because I don’t think people often read what’s fully there, but have that knee jerk reaction.
Now, I don’t certainly like necessarily pre authorization, it’s a little bit of a hassle, but at the same token, what does this include? So let’s talk about what has occurred. Yes, UnitedHealthcare, Optum, and Humana are doing a pre authorization, but I want everyone to note it says here, effective September 1st.
UnitedHealthcareOptimum will require prior authorization for the following services delivered in an office and outpatient hospital settings. That means in our office, of course, and I guess if you were in an outpatient type clinic, that would fit. But notice what it says. Medicare covered chiropractic services when billed with an AT modifier.
So what does this mean? This means this is covered for the Medicare Part C plans. This is not regular UnitedHealthcare. So you are not required for regular UnitedHealthcare if you belong to Optum through that. There is still no pre authorization required, except now. For the chiropractic Medicare Advantage plans or so called Part C.
Now this is a lot of people because realize this year has been the first year that more people have Medicare Part C or the private insurance Medicare compared to the. Standard Medicare Part B. Now, in my opinion, I like it. Medicare Part C plans, for one, always have to cover exactly what Medicare covers.
They have to cover spine manipulation related to subluxation. Great. But these Medicare Advantage plans, in order to be attractive, why would I buy a Part C plan, or even enroll, I’m not going to say you’re going to buy it, but enroll in it when it doesn’t give me anything extra? So therefore, what these Part C plans do is sweeten the pot.
Often, what they’ll do is not only cover spinal manipulation, I’m sure some of you have seen this, they will cover exams, therapies, x rays, and so on. And so what they’re doing now, again, only for the Medicare Part C plans, are they requiring authorization. If you’re not billing with an AT, which is of course used for the Medicare plans, remember, because Medicare Advantage plans Or just like Medicare Part B, you still bill the same way, and you would use an AT modifier.
So the pre authorization has begun. Now, let’s talk about what does that mean. It’s the pre authorization for chiropractic manipulation. Spinal. Spinal. 989404142 when you put an AT modifier. Now you might look and say, well, that’s just for those codes. I guess they’re not covering anything else. No, actually it also is for outpatient therapies.
Now, some of these we’re not going to do, but your standard physical medicine, your heat and massage and manual therapy and exercise are all included in here as well. So that means if you’re doing therapies, it would be required as well. Now you might look at this and go, Hey, Sam, I don’t see 98943. And you’re correct.
So one of the things I’d be interested in seeing, and I don’t know this, I’ve written to them to see, how are they going to respond to 98943? Because remember, 98943 does not require an AT. Therefore, does it need authorization? That’s a loophole. We’ll have to see what goes on. But for the most part, it does mean now, after the first visit, you will need authorization.
Now notice what I said, After the first visit. Now this applies to all UnitedHealthcare Medicare Advantage nationally. The ones that excludes are the dual complete plans. Those don’t require authorization because those are usually for very sick people. I don’t think we generally see. Those, because it’s a special needs policy, but possibly, and realize it doesn’t change anything.
There’s current pre authorization in states such as Arkansas, Georgia, South Carolina, and New Jersey. So if you’re in those states, you’re thinking, who cares? I’ve already been doing that. So needless to say, it’s going to be new for everyone else. Now, what does it mean? It’s the treatment. It is not the initial evaluation.
So can you imagine a patient calls you, says, my back is hurting. And then you have to do a pre authorization for an exam. They’re not requiring that. Now don’t do any treatment first visit. They’re not authorizing treatment. They’re authorizing the initial exam. So you’re going to do an exam, request care, and then they’ll allow it.
Now, in my opinion, that’s a big hassle because it requires the patient to visit twice. That means they can’t get care right away, so it delays. They’re coming with a rip roaring headache. Oh, I can’t treat you today. We got to wait. So how frustrating is that? And I think you’re gonna find there’s a lot of pushback on this, not just from chiropractic, physical therapists as well, and realize even medical providers, there was just a big article by the AMA showing how pre authorization limits the amount of care that’s necessary and people suffer.
I don’t disagree with that. My opinion would be If you pay for the care and you begin to see where you don’t think it’s medically necessary then don’t pay for it. Request records. But why do all this work? Of course, this is partly to frustrate most of us and think, oh my God, what a hassle this is going to be.
And I’m not going to say it’s not going to be a bit of a hassle, but I think we can make it a little bit simpler. What you’re going to do is, after the first visit, is request care with a pretty standard protocol. Don’t get fancy. A standard protocol means via Medicare. The treatment plan will require, authorization for a number of visits, but look at the diagnosis.
If you have someone with back pain, M54 or 59, compared to lumbar radiculopathy or disc or sprain strain, that’s certainly going to be a different level of care because pain means you don’t really know. It’s going to be just like Medicare in a way. Always make sure you understand that necessity is going to be based upon what you’re telling the insurance.
How acute is the condition changing the date and block 14, whether it’s chronic, it can be a flare up, but also what is really wrong now, of course it is going to require a subluxation as the primary diagnosis. Don’t get away from that. And I’m going to recommend stick with the M99 05. That way we’re not going to have any issue because you know some states have it, some states don’t with 11s.
Just stick with those, but you will follow and you’ll notice it follows the Medicare LCD or what we call the local coverage determination. Now, subluxation by itself is not going to be enough. Of course, a person with a subluxation May or may not need care. I do this often at our seminars. I’ll ask people, Hey, you got a patient with subluxation.
How many visits do they need? Now, philosophically, we can make a big argument, but what if their subluxation completely asymptomatic? No findings. Now, I would argue that should still be adjusted, but can I really justify medical necessity in a world that we have now with insurance reimbursement? No. Just like Medicare, the patient must have a significant health problem in the form of a neuromusculoskeletal condition, necessitating treatment and manipulative services rendered, and they must be a direct therapeutic relationship.
Oh, I’m adjusting the lumbar spine, L4 for radiculopathy and so forth. Is that very complicated? No. Just like any other Medicare patient. By the way, that’s not new. That’s what we’ve already been doing with these Medicare Advantage plans anyway. Now, bottom line though is subluxation is still primary and you do still need to show how you did the subluxation.
Now, keep in mind, you’re not required to do an x ray for subluxation. You can do a physical exam. My opinion on this is, I don’t think I’m going to put force. into a elderly spine without looking at an x ray to make sure there’s no underlying problems that might be there that I wouldn’t otherwise see.
Osteoporosis, significant degeneration, things of that nature that could be present. So I’m always going to have an x ray, so that’s going to be a given, though I can still find it by Physical exam, the so called PART, P A R T. That’s fine as well. You can certainly do that. Now, what does it mean though when you’re saying this person has the problem?
Medicare categorizes it into a few and I want to highlight so you can start to realize how are you going to get care? Because I think this is what I want to really emphasize to you. You’re needing to get care that’s going to be helpful to the patient. So how do we do this? It subluxation, a patient’s considered, a patient’s condition is considered acute when the patient is being treated for a new injury.
Identified by x ray or physical exam as specified.
level of pain and dysfunction. Emphasize here, use some level of outcome assessment, whether you’re going to use something simple like a general pain index, a pain interference form. You certainly can go with an Oswestry or similar, but those are lengthy. I do something simpler. Bottom line is chiropractic works.
Show it. Because if you’re going to get a second level of care or second authorization, you have to show the patient’s improved and they’re going to focus on function, not just pain. Pain without dysfunction Doesn’t change a lot. The next thing they look at is is it an acute subluxation? But keep in mind, Medicare patients, I’m going to be seeing one in another year, are going to be considered chronic.
And I think most of us will, because it says here, a patient’s condition is considered chronic when it’s not expected to significantly improve or be resolved with further treatment, as in the case of an acute condition. But where continued therapy can be expected to result in some functional improvement.
In other words, chronic conditions, you’re going to get a flare up. An exacerbation of recourse of some type, you’re going to treat, get it back level. And then when it’s level, good, they’re stable. Then when it gets acute flare up, we go back again to it. Bottom line is, notice they’re showing that, just show improvement.
You want to get more care, show me that you’re making the patient better. You’re not just giving them maintenance. Now how does Medicare view this? They view one way as an exacerbation. It says an exacerbation is a temporary marked deterioration of the patient’s condition due to a flare up of the condition being treated.
This must be documented on the claim form by updating the date in Block 14. In other words, I don’t want to treat someone off of a flare up four years ago. Patients with chronic conditions, they get better, but they flare up again. Picture a patient with sciatica in January. You treat them. By March, they’re like, eh, I feel pretty good.
Perfect. But then come June or maybe even sooner came back. It’s the same diagnosis but a new episode. Update the date. Show me that there’s been an exacerbation or some type of FLARA. Medicare expectation is many of these patients are probably going to need 20 25, maybe as many as 40 visits in a year.
Not all at the same time, but in episodes. Get them better, get them stabilized. Now, I know partners will argue I would love to be able to do it. If I see them every other week, they’ll do much better. I don’t necessarily disagree with that, philosophically. But from an insurance standpoint, no. Remember, it is sick insurance, not health insurance.
Demonstrating exacerbation. Or, let’s look at this one. And this is one that I think sometimes we forget. What does Medicare call a recurrence? In other words, you ever have a patient that comes in and goes, I didn’t do anything. Medicare said, oh, I slept funny last night, I twisted, I picked up something, whatever, went to the gym.
But how many people come in and say, it’s just, it’s been hurting? What’s going on? That’s what we call a recurrence because it says a recurrence is a return of symptoms of a previously treated condition That has been quiescent for 30 days or more. In other words, they’re feeling good And I don’t know what I did it came back now The truth is I think there is something that does it but the patient can’t recall in their mind like what thing did I do?
It may be a combination of things Sitting for a long time in the car and then doing other things that you really can’t pinpoint that one thing You But all cumulative are there. So make sure you’re highlighting when you’re requesting care, what’s going on with an exacerbation or recurrence. Now, how do we do this?
UnitedHealthcare is creating, there’s a website, uhc. com, go there. They’re going to call it a patient summary form. You should be able to fill it in. And I’m going to tell you, it’s going to emphasize outcomes. You can make attachments, but demonstrate that the patient is improving or going to improving the expectations of it.
Give me that significant diagnosis. I don’t think this will be anything more than the hassle of doing that. I don’t think we’re going to see a big change in visits, frankly. Assuming you’re reasonable with diagnosis and have good findings. Again, I’m going to emphasize to you, focus on function, not pain.
And remember, when you use terms like maintenance, this is when Medicare says no. It says here, maintenance therapy includes services that seek to prevent disease, promote health, prolong and enhance the quality of life, or maintain and prevent the deterioration of a chronic condition. I agree with that. I do.
That’s a cash patient though, that is not insurance, and that’s the difference of our society. We’re going to move some patients into that a little bit, and I think we have as a profession. But realize, insurance is not that. They’re not there to necessarily keep you healthy. I know that seems counterintuitive, but in a way it is.
Think of it, have you ever used your insurance to really help you? Now, I’m not saying some aren’t trying a little bit. But for the most part, they’re waiting to get sick. So here it says, when further clinical improvement cannot be reasonably expected from continuous ongoing care. Notice clinical improvement, not my pain is better, but I can only go down to my knees.
I can’t sit for an extended time. Now I can get down to my shins. Goal. It’s to touch their toes. That’s what you want to focus on. And if you do that, I don’t think you’re going to have a whole lot of problem. Now, if you’re a network member with me, certainly get in contact with me. Let’s talk about it as you start to send these in.
Let’s help you formulate how this does. That’s what we do. That’s what I do with our seminars. But also our one on one service. What I want to make sure is that you don’t have any misunderstanding. Does this affect regular United plans? It does not. Medicare Advantage and the same for Humana plans. Humana plans.
One thing that’s weird though, for Humana plans, keep in mind, they don’t use modifier AT, they use 7, instead. And so they put it on there, but again, they’re going to do the same thing looking for that. Is this something that I like? No. Does it create another factor that we have to do? Yes. Is it a hassle?
Yes. However, consider the number of people that are Medicare. 10, 000 a day for the next five years, I think. That’s a lot of people. In fact, most of us, because I’m in the age, I’m 64. I’ll be, I’m another year, I’ll be 65. Nonetheless, there’s a lot of us and realize the patients of that age. Are not the same as they were 40 years ago.
Think of how people in their sixties are. That’s going to be a lot of people and they may still be working, but still have the advantage of these policies. Don’t be afraid of them. Use them. I think your reimbursements, by the way, you’re going to get probably assuming an adjustment in a therapy in the 60, if you’re doing a couple of theories, maybe even 90 range.
So certainly not bad. But again, be careful of the people that have that, hair on fire. Oh my God, everything’s going, no, slow down, go to the website, start requesting care. I don’t think there’ll be a problem. In fact, what I would suggest is start to notice the things they ask for. In my dad’s practice, we belong to ASH.
And what I learned was they had certain things that they look for. I wanted to make sure to give that to them. You know what I found they look for? Improvement. The best way to demonstrate improvement. Objective findings, of course, but outcome assessments, easy. Not hard and always can demonstrate your care.
As always, we want to be there to help the H. J. Ross company. We’re doing a seminar coming up the end of this month that will cover the 2025 diagnosis codes that I mentioned that are changing. We want you to be a part of that as well as get the one on one help. I’m going to say to everyone, thank you. And I’ll see you next time.
Take care of my friends.
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