How insurance companies use your money to audit other chiropractors

By Matt Wurm |

Posted July 1, 2019

Hey Ron, Dr Brian Capra here from Genesis Chiropractic Software. We have gone over the past couple of days a couple of high level things about insurance companies and your collections and your revenues. Number one, insurance companies make their money by collecting interest on the money that they should have already paid you, and they should have already paid you the day you saw the patient, so there’s no reason why we should be waiting weeks for check from insurance companies. Number two, we learned that the whole system is actually rig to allow them to create this environment where they can not pay or not even respond to you for 30 days. There is no reason why they should be allowed to do that. In order to do that, they had to actually collude against physicians and that there was a law made to actually make them exempt from antitrust law, allowing them to actually rig this whole system and make all these crazy rules.

Now we’re gonna talk about some of the tactics, the actual real life examples of what they are actually doing. Now that we know how they make their money and that they’ve actually ranked this whole system, you’ll start to see that all this is really nonsense. Remember, they should pay you the minute you’re finished adjusting a patient. There’s nothing preventing them technically from doing that. Let’s make sure we’re keeping that in mind as we go through these things. I’m going to go over just some high level tactics that they use. Just generalities first. Then we’ll go a little bit deeper in. Number one, they make it difficult for you to get the claim to them. We’ll talk more about that.

They make it difficult for you to prove that the claim was necessary. They pay very slowly, or they actually just respond to you very slowly. Every time you send a claim or resubmitted claim, it’s a slow response time. They pay you less than they should. That’s very sneaky. I’m going to get back into that a little bit later. And then after they’ve paid you and the patient’s already out of the picture, they’re going to take your money back.

I’m going to keep on going through here, a couple more things. Another thing that they love to do, and this is, again kind of, if you ask me, very sneaky, very subtle. They put themselves between you and the patient. If you think about it, the doctor has to make the claim properly, right? You have to submit the claim, and I say doctor, your office, whoever, you have to prove that it was necessary. It’s your fault if it takes too long for the payment to come for their care. It’s your fault if you charge too much or more than is the allowable amount in that area. And it’s your fault if this claim comes back later on and it wasn’t necessary and they accuse, and you have to go through an audit and accuse you of fraud, that was all your fault.

And so you think about patients getting EOBs and calling their insurance company, and they’re being told, “Oh yeah, the doctor hasn’t submitted. Oh yeah, they didn’t prove necessity. We’re waiting for documentation.” It’s been taking too long. Were they charged? Why is there a balance? The patient’s asking the insurance company. They’re just saying, “Oh yeah, they charge more than we allow.” The first call, we’re lucky if they call our office for balances. Right? We’ve got to keep these things in mind as we go along here.

Let’s dive a little bit deeper. What are they allowed to do? They have 30 days to pay. Ridiculous right off the bat. There’s no reason why that should happen. They should pay you right away. Nothing preventing, nothing preventing them from doing that. Each patient’s coverage is different. We have tons of different plans and groups and all this stuff. Why is that? Why is it so complex? It’s not because it’s better for patients. It’s because it’s better for their interest gained on your money. They’re just trying to drag out this payment cycle as long as they can. Complex coding. Right? I have a list here. Diagnosis codes. You know the ICD-10 came out. That made it a hundred times more complicated, literally. The order of your diagnosis codes, in some places in some carriers, actually matters. Which diagnosis code you put first. The CPT code, obviously, with different levels, right, so you’re 989 codes and your exam codes all have different levels built in for you to be able to tell them which level of service you did. Does it really matter that much?

The modifiers that go along with this, the diagnosis code linking, the units. We have time codes. We have one on one codes versus group codes. It’s really, it really doesn’t have to be that complicated. It’s there and they always love to tell us, “Oh, it’s so that we can track the, the patient’s progress ,and we want to make sure that it’s based on the quality of the care that the doctor’s giving and then we’re actually paying for the right care.” Then you got the HCA form, which has 9 million fields on it, all of which have to be filled out perfectly in order for that claim to be accepted on the other side. Obviously technology is helping that out.

Then you have the EOBs. Every insurance company has, when you get denials, there’s denial codes and that’s their explanation. Every insurance company has a different code and different explanation that you’re supposed to know. And so again, it makes it very complicated for you to just to figure out why things were denied. Probably one of the most sneaky things that they do, and this happens a lot and in Genesis we see this a lot. We have a lot of automations to prevent this. You would never know. It’s really hard for your biller in your office to track this type of thing. But they’ll, let’s say, allow $40 for an adjustment and then they pay you the 80% of the 40 bucks and that whole thing. Well, you’re getting paid, you’re getting paid, your EOBs are coming in, you’re very busy, your biller’s very busy, but you’re just, you know, depositing checks. It’s not denied, so you don’t think to follow up on it.

All of a sudden, two months later, the 40 becomes a 38 and you never see it. It’s one sneaky way for them to basically underpay you, keep even more of your money without you ever following up. And in a lot of ways, we’ll talk about some other tactics they use. Is it really even financially feasible for you to be able to follow up on those things? It’s, in many cases, not even feasible for you to spend 15 minutes on a phone call to get an extra two bucks. Actually 80% of two bucks.

We all know documentation is very ambiguous. We have SOAP notes, subjective objective, ADL assessment plan. It’s all craziness. You may want to take notes so you remember what you did on patients. That’s great. That’s actually good for patient care. But as far as it being required for you to get paid, should never be a case matching codes, obviously, and to your documentation, another example where it’s completely unnecessary for them to do this.

I want to make sure you guys understand that all of this thing is rigged. All these rules, they don’t need to be there, and that the whole point of this thing is they’re playing chess while you’re playing checkers, really. I’ll get into more tactics and things later on in some future videos about how you can fight back against insurance companies and prevent them from just raking you over the coals.

Now of course, the last and final thing that they’ll do here is, and kind of putting themselves between you and the patient is you’ve processed all your claims, you’ve been making money for years, your patient is totally out of the picture, and now they’re going to come back and audit you and take the money back. Patient’s out of the picture, so they’ll never even know about it except for the cases where they send letters to patients or go to patients houses, which actually happens, but they’re going to go and take all that money and all that interest that they’ve earned, reinvest it and actually audit you or other chiropractors.

Here’s a fun fact. For every dollar they invest in an audit, they expect to make $14 back. We’ll talk more about audits in the future ,and we’ll talk more about how they find the right people to audit and make sure they get that 14 to one return on investment. But imagine this system where they, you could get paid the minute you see a patient, nothing technically preventing that from happening except the laws and rules that have been put in place because of real collusion, in this case, excuse me, real collusion in this in this case, and they’ve rigged the entire system just to keep your money longer, to gain interest on it and reinvest it again to get a 14 to one return on your money. Let’s all keep that in mind. I’m going to take a little bit deeper dive in future videos into all those different things and the processes and the people, how they leverage people, process, technology, and even more about the audits.

Thanks for your time. Hope you enjoyed this. Stay tuned next time and we’ll go over some more. https://genesischiropracticsoftware.com/

Matt Wurm