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Greetings, friends and colleagues. It’s Sam Collins, the coding and billing expert for chiropractic and for ChiroSecure and you, giving you another episode. Let’s talk about something I hear quite a bit. I travel across the country, in fact, even in the world for an extent, and I get this question often, Sam, I have a policy that says it has 25 visits, or 30, or 40.
Does that mean I get to use all those visits? Does the patient get a choice to it? And this is something that comes up quite a bit. Does it mean that you get all 25? No matter what. So let’s go to the slides. Let’s talk about that. What does it mean when a policy says it has a set number of visits? What does it really mean?
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Does it really mean when a policy says 25, do you get all 25? Well, I would say yes, but is it automatic is really the issue that does a patient have a right to just say, I can use it at my discretion. If I have 25 visits, I think you get a lot of people that say, Oh, good. I’m going to come two times per month or whatever the case may be.
If it’s 40 visits, three times and so forth. So that’s where we have to be careful because is it really automatic? By example, what if a person just says, Hey, you know what? Getting chiropractic feels really good. It makes me feel more energy. I feel less tense. All those things, very positive. But would that be seen as medically necessary?
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So some things we have to consider is that 25 doesn’t necessarily mean it’s 25. It means it’s 25 if it’s medically necessary. So that still always comes back. Now what we need to do though is to look and say, well, yes, if a person is enough of an injury or sickness, 25 without question, but what about Where we start to get in that kind of gray area of, well, is it still corrective care or is it truly a maintenance care?
What does it really mean? Is it automatic? Is it two visits per month? Is it, what if it’s maintenance? Does it really allow that? You know, what if it’s maintenance care? Do they allow that type of care? It could be, but I would say be careful, generally not. We have to think of medically necessary. Is the service aimed at a diagnosis and treatment of a musculoskeletal related condition?
Realize that chiropractic for insurance purposes. relates to medically necessary for neuromusculoskeletal conditions. Now, a chiropractor can treat the human condition, and a person can come in for many things, but I’m talking about what does insurance pay for. They will always tell us it’s got to be a neuromusculoskeletal disorder.
Now, a lot relates to that, but we need a diagnosis that affects that. The condition has the potential to improve. You know, so in other words, notice medically necessary means that the person can get better. Now, realize sometimes better is, I have a lot of pain. Can I reduce the pain? Yeah. Well, what does reducing pain do?
Increases function. So we have to make sure that we can show not only does it reduce pain, but it increases function. That doesn’t mean it’s forever. We’re going to have some patients with chronic conditions. That we’re going to treat and get them better, more stable, but then unfortunately it’s going to flare up.
That will continue to be medically necessary. The improvement though has to be seen and documented. Make sure that you can see some type of successive objective measurements. over some period of time or defined period of time. Now what I’ll say here is just be mindful that no one expects a person to get better in a sequence where it’s always improving, but that it’s improving over time.
If you were to graph it, there’s improvement. We all know there are going to be patients with ebbs and flows, or maybe there’s a week or two where it kind of goes down. They do a little too much. But overall, if you look at it, it’s improving. So the issue will be making sure that no matter what the number of visits are allowed or if it’s unlimited.
Can we demonstrate the care is medically necessary by demonstrating the patient’s improving? I’m going to implore you what can save you on this type of issue is making sure you have good objective evidence Not just subjective how I feel but objective but realize we can turn a lot of subjectives To an objective if their pain levels in eight What is it that they cannot do when it’s an 8?
Can’t touch their toes, can’t tie their shoe, whatever the case may be. Demonstrate that when it’s a 6, Oh, I can go down and touch, you know, touch my toes, but I can’t reach beyond that. You know, I still have a lot of pain. So, in other words, there’s some objective changes. Keep in mind, the simplest way to do this Please make sure you’re using some type of outcome assessment forms.
I’m going to recommend two, General Pain Index or the Pain Interference Short Forms. Those are easy. The VA even is the one that prefers it along with Medicare. And I think chiropractic does something that almost no other profession does. When a person comes in, they get objectively better. Now I’m not saying instantaneously, but it’s very hard for a person to keep coming back to a chiropractor if they’re not improving.
We just have to make sure that we’ve got documentation of it. Always have that evidence. What is not covered, or what is maintenance, though, is where we have to be careful. This is how insurance company defines maintenance. Maintenance preventative care is defined as elective health care that is typically long term by definition, not therapeutically necessary, but provided at intervals, preferably regular, of course, to prevent disease, promote health, and enhance the quality of life.
Well, I do think that’s truly health care. That last sentence. Prevent disease, promote health, and enhance the quality of life is health care. But is that what health insurance is? No, health insurance is sick insurance. So we have to make sure that are we demonstrating that there’s improvement. Now realize a person who has a chronic condition may need something more that we might call supportive care, but we have to be careful.
Ongoing preventative maintenance care may include patient education, screening procedures, risk, home exercise. So they’re wondering why aren’t they just doing that. We want to show that. It requires care beyond it. So this is where you want to start to understand how do we define it when it is long term, maybe when it is 25 visits and it’s not something that the patient’s getting exponentially better, but has ebbs and flows.
This can be termed supportive care. This definition comes directly from Cigna Health Insurance. It says, Supportive care, also referred to ongoing care or long term treatment or care, may be necessary as a treatment for individuals who have reached a maximum benefit, but fail to sustain that benefit and progressively deteriorate.
So in other words, flare up, show me that th well, home exercise, they off. The potential for th dependency and ongoing ca in the planning. So make know before the patient c flare up, if you will, th what we’ve told them to d I say exercise, I mean, w Exercises too, but have we given them preventative things to do?
Have we provided them with a home exercise protocol? And we’re showing that doing that has not resolved it, but the care can. So when someone says they get 25 visits, I don’t want to say they don’t get them. We have to show that the care is necessary in some way, beyond if it just being elective, like I like it.
Like by example, how many people will get a massage once a week if insurance covered it? Sign me up. The difference is, can we demonstrate that massage is going to do something beyond just a feel good? So this is where we always have to find a focus in on what medical necessity is. First and foremost, for chiropractic, it must be documented that the patient is making some type of Improvement, but that improvement is on what type of condition?
Musculoskeletal. So, if we’re showing improvement within two weeks of care, I think we’re fine. In fact, I think most of us would agree. If you’re treating a person for two weeks and they’re literally making no improvement and they’ve had six visits, I think we all panic a little bit. Now, I’m not saying that person is cured, but it means are they showing some level of improvement?
If no improvement is documented within two weeks, well, what do we do? Should we just go, you’re released? No. You want to change the protocol. Modify the treatment. What can I do differently? Is there a different type of manipulation? Is there some other type of mobilizations I might do? Might I add in some therapies?
What changes can we make now after that has gone on and you’ve gone a month without improvement? Then I would say, okay, maybe not at that point. Maybe we do need to refer out or understand our care is not going to work. But here’s the beauty of chiropractic. I want everyone to think for a moment. Have you ever been to a medical provider and when you left you went, oh my god.
I feel so good right now. Now, I’m not saying that as a put down, but the only time I think that truly happens with a medical provider is when they give you the report of a biopsy that came back negative. You don’t feel better, you’re just relieved. But in a chiropractic office, when you come in, does that patient feel better after one, two, three, or four visits?
Absolutely. That’s powerful. Now, the key is, are we demonstrating that objectively? So long as you’re doing that, I think you’re fine. Because think of it, what treatment does a medical provider give? I can’t think of any beyond surgery. They’re going to prescribe, whether it’s drugs or therapies, but I’d even go so far as even a physical therapy setting.
How many people after one physical therapy benefit can feel the same difference they would in a chiropractic? I’m not saying physical therapy doesn’t have its place, but an exercise protocol doesn’t make a change overnight. In fact, sometimes, the first time you do the exercise, You may feel worse the next day.
You feel a little better when it’s warmed up. So understand that chiropractic medical necessity, I think, is relatively simple to prove because we can demonstrate it. But give me some objectives. It means that once they’ve reached maximum therapeutic benefit, okay, not medically necessary or maybe supportive, but I think we can always demonstrate when, if they hit that point, here’s one to keep in mind, take a look at this.
This is Costco insurance. You notice for Costco, it says here that currently chiropractic services are covered as an alternative care benefit and it may have a co pay, but it says you get 20 combined visits for acupuncture, chiropractic, and homeopathic. But is that really what it covers? Let’s read further.
Beginning January of this year, chiropractic will be instead be covered as a short term rehabilitation benefits. That means it’ll be covered, but I want to highlight, too, that you’ll be limited to 30 chiropractic visits per condition, unless Aetna, who’s the coverage for Costco, of course, approves more because the actual maximum is 90 per year.
So notice they’re not saying a person gets 90 per year. They do, but they’re highlighting what we’re going to do is give you visits that probably per condition that give you 30. Now what if a person has a condition that significantly flares up? You can demonstrate improvement. This goes back and forth.
Would that allow that care to potentially hit 90? You bet. But notice what it’s coming back to. Medical necessity. The care really is more profound based on are you making the patient better? Is the patient improving as a result of care? Without that, that’s where we’re going to have a problem. So keep in mind, 25 visits may be 25 visits, but is it absolutely automatic?
Not necessarily. Always please keep in mind that we’re the ones that have to inform the patient because the patient’s going to hear this and go, well I get 25 visits, doggone it, I want to use them all. I don’t disagree if they’re medically necessary, but we have to make the patient informed. So we need a financial agreement with every patient.
Notice what this says. Many insurance policies do cover chiropractic care. But this office makes no representation that yours does. We’re not guaranteeing a thing. Part of the no surprise act. Insurance policies may vary greatly in terms of deductible and percentage of coverage for chiropractic care.
Because of the variance from one policy to another, we require you the patient be personally responsible for the payment of your deductibles as well as any unpaid balances. In other words, we’re putting them on notice. We’re going to bill your insurance. We’re going to do the best to get the best possible benefit for you, but are we guaranteeing it?
Ultimately, you’re the responsible party. If you have insurance, we’ll bill as a courtesy, but payment for deductibles, if it has not been met, is the responsibility of the patient, as well as any co payment or remaining balance. In other words, we’re putting on notice the service has value, and it’s not just based upon insurance.
We want to be careful, and this is why practices always should have a practice that is balanced. With an understanding of cash and insurance, and frankly, they’re always combined. I don’t know very few insurances that pay 100%. You can throw in some personal injury, maybe VA, but outside of that, there’s always a responsibility which thinks patients need to be responsible and understand that.
That way they’re not just thinking, well, I’m gonna come in because it’s free. You’re going to come in because the service is good and has a value, and people will pay for value. This is Sam Collins, your coding and billing expert, and don’t forget, you really need one on one help. You want those outcome assessment forms?
How many of you are network members with me? We have those available for you. Until next time, my friends, thank you very much.
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