Chiropractors are always looking for newer and more innovative ways to expand their practice with explosive growth.  Discover the difference between successful chiropractors and unsuccessful chiropractors! Learn from the success of Dr. Fred DiDomenico with this podcast.

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Announcer: Welcome to Practice Growth Strategies. Bringing you tips and strategies from the best in the business. To find exclusive workflow, scheduling documentation, billing, and all of the tools your practice needs in one easy to use platform, visit Now here’s your host Dr. Tabor Smith.

Dr. Tabor: Well, hello and welcome, everybody. We are getting started here with a webinar. This webinar is called Helping You Keep What You’ve Built. Learning the secrets of how to keep every penny you’ve earned away from Medicare and insurance audits, while protecting the practice you’ve worked so hard to build. And guys, that says it all right there. That’s exactly why I am so excited to hear what Dr. Davila has to say, because I’m on a lot of webinars and you guys are probably on a lot of webinars. And it’s a great way to learn and to grow your practice.

A lot of times there’s all these sexy titles about how to get new patients and explode your practice. We forget that we’ve got to take care of what we got. And if we’re not doing things the right way, we’re going to get bit. And we’re going to get bit bad. And it can be gone in a heartbeat. And so it doesn’t matter if you’re all cash. It doesn’t matter if you’re all insurance. It doesn’t matter if you’re both. You have to do things right.

And that’s when we have the expert, the absolute head of his field when it comes to compliance, when it comes to procedures in chiropractic, and that’s Dr. Davila. And Dr. Davila is the president and CEO of Custom Chiro Solutions. He’s a Palmer grad. But he defends chiropractors. He works to defend chiropractors against insurance, against the board. And he’s just dedicating his time tonight here to help educate us and to provide huge value to us. So I’m not going to spend a long time introducing him. Dr. Davila, I’m going to go ahead and turn it over to you. But I just want you to know that there’s the sincere thank you for being here and for sharing this information with us.

Dr. Davila: Tabor, thank you. I’m honored. I hope I live up to that intro. I really do. Thanks.

Dr. Tabor: You bet.

Dr. Davila: Yeah. So let’s get into this. I know on the East Coast it’s 8, and if you’re in the Midwest, it’s 7. And we want to get you guys out of here but give you some information. What I wanted to go through today really is just the tone of the information. Tabor, go to next slide. I want everyone to understand exactly what it is that . . .

Dr. Tabor: Sometimes there’s a little delay in the slides.

Dr. Davila: No problem. I want people to understand what it is that where they’re going to get their information from. My information doesn’t come from the fact that I went to a class and got dubbed the knight of compliance, or whatever. The information I’m going to give you really comes from a couple different places. One, it comes from obviously working with clients and getting on calls with nurses and administrators to find out what they’re looking for when it comes to dealing with clients who were obviously having issues. That’s one way I get my information. So that’s recent stuff and we can talk a little bit about that tonight.

In addition, I also consult for chiropractic networks. And in doing so, the information I get from them is them telling me this is what’s wrong with our provider. I would like you to talk to this provider. And that information comes fast and furious. So when it comes down to what the carriers are looking for, and when it comes to profiling a doctor, the information I’m getting is real time information.

In addition, I’m also on faculty. I teach this stuff at Sherman. I’m on faculty with them. I also work with Parker College as far as compliance with them, and managing some of their risks when it comes to what they do in their clinics. So the information also comes from that world also, as far as academia and getting it out to students.

But the key information that I have gained over years was a couple years ago, actually it’s about eight, nine years ago, I was actually on the Medicare board in South Carolina with Palmetto GBA. And it was called the Care Advisor Committee. And back then I happened to have the chance to rewrite policy and then train nurses.

So when working with nurses, and continuing to keep in touch with them over time, I started to find out what carriers are looking for. And once I started to find out what they’re looking for, I was able to do something that’s very, very important. And then while we were getting ready, Tabor was trying to tell me, “You really should look at Mac.”

And then it’s funny because he’s looking at a website. And I’m on a PC, and I’m looking at a website. And there’s something that runs these websites that allows both of us with two different types of machines to be able to see the website. And that’s called Java. And that JavaScript that runs, and you see it running in the bottom of your screen. Really what it is, it’s a translator. So it allows the translation of a website for you to be able to see it. What you’re looking at now is translated onto your computer.

Now, the reason why I say that is because what I’ve been able to do, or dare I say, blessed to have been able to explain to people is really how to translate what carriers are looking for into chiro speak. And if I could do that into chiro speak, the beauty is that the doctors I’m working with are able to understand what carriers are looking for. And in addition, be able to practice the way they want.

So today what we’re going to go through is how are you able to do what you like to do, but still be able to not have to feel like you’re serving two masters? Where you can actually serve the patient but allow the chips to fall where they may. And we’re going to go through some of that information. That way you know how to be able to protect what you’ve built. And especially, if you have a coach and they’re telling you how to build a practice, it’s one thing to go through it and build it, and another thing to go ahead and have someone help you to be able to defend it. It’s two different things.

So Tabor, if you go to the next slide, I want to bring in some of the older doctors that may be out there. When they look at it, they go, “Oh, yeah. I’ve been out in practice for a while,” those types of things. And those doctors who’ve been out in practice a while go, “I remember the days when I sent a claim in and it got paid.” Those days are long gone. In fact, there are days when you send a paper claim in or an electronic claim in and what you get back really isn’t anything more than a letter stating, “We would like more information.”

Now, as we look at that process, what’s really funny is, you can send that letter in and the next time you get anything back from anybody, they finally send you a check. And then they’ll send you another letter, and they want the money back. So the business of insurance has really changed over the last couple years. And if you haven’t been able to catch up to that, that may be a problem. So we want to definitely make sure that we’re able to stay with the ability to continue to build, and continue to go, and take your practice forward.

So Tabor, go to the next slide for me. The key to be able to understand this, and the reason why I say the difference between older doctors versus newer doctors is that it’s really the business of what’s called medical necessity. Now I say medical necessity because as we look at the term medical necessity, the issue really is that the rules have changed over time. And when I say the rules have changed over time, what I mean is not the policy. If you go back and read Medicare policy, it really hasn’t changed very much since 2000. So we’ve been working under the same basic policy for the last 15 years or so. But what has changed is really the way it’s adjudicated. Now here’s a great example.

A couple years ago I was working with Parker and I sent a compliance audit for them. And they had referred someone to me from another college. And they wanted to know what we were doing. And the guy started out the conversation with, “I’ve been looking for rules changes over the last couple of years in Medicare policy and I haven’t seen any.” And my comment back to him was, “Well if you do, let me know because there haven’t been any that I’m aware of.”

He’s like, “Well how come we’re having all these changes in how claims are being judged or adjudicated?” And I said, “Well, it’s not the fact that the policy has changed. It’s they’ve picked out certain words to be able to say this is what we’re going to hang our hat on when we talk to a doctor about what is medically necessary and what isn’t.”

Now, really what we’re talking about here is those sitting in judgment. Really that’s come from a couple different places like administrative law judges and things like that. And that’s really come across, especially when the OIG does reviews, they’ve set up ways in which they’re looking at policies. And there’s a great way to look at it.

If you look at the old way of doing a CERT review, or a comprehensive error rate retesting, Medicare came up with that process. And there was an error rate of like 14 or 15%. And that was only looking at one date of service. Well the OIG, bunch of attorneys and auditors that go around and they go, “Well, let’s see if this is really true.” And they changed the way the audits went. And they looked at a grouping of dates. And when that happened, the error rate changed from 13, 14, 15% and went all the way up to as much as 67% with all the errors added in. So the policies really didn’t change as much as the way they reviewed. So that’s really what we need to talk about is what are we looking at when we talk about reviewing?

So Tabor, if you go to the next slide, it brings up this whole business of compliance. And when I say business of compliance, I mean really, what do we have to do business-wise, because the business part of it is how do we protect ourselves knowing that the government is looking for different ways to be able to keep money, or be able to stop paying doctors. So if you look at some of the initial CERT, not CERT review, but RAC reviews. Those RAC reviews that originally happened in the three year test. And in the three year testing, they corrected something like $1 billion back in three years only in New York, Florida, and California. It’s ridiculous.

When that RAC review, when that initial program went in just as a test program, they didn’t even take it back to Congress. CMS implemented it right away because it was a very, very profitable way for dollars invested to get money back from an audit. So this whole process is becoming very, very profitable back to the government. So we need to be able to know what we’re doing in order to protect what we’re building. And that’s the reason why we’re talking about building what it is. So really, it’s even gotten worse. It’s not just those things.

Tabor, go to the next slide. You’ll see that it’s really about things such as the latest Patient Protection and Affordable Care Act. The government has found that not only are these RAC reviews working, but they’re also putting money into this PPACA Act from 2011, to $295 million in fraud enforcement. Over the next five years its going to be up to 250 million. While the government is contracting with sequestration and everything else, they’re guaranteeing money to put into auditors, which means they’re coming after us.

Now, before you start to say, “Oh, this is such a negative thing.” I don’t want it to be negative. What I want it to be is empowering, because there’s no reason to be afraid of the boogeyman. The boogeyman’s out there and if you don’t know what actually is going on, then you just become scared and you start to down code and it becomes a bigger issue. So I want you to know what’s out there. And I want you to know because what the government is doing, is they’re putting money in the hands of the OIG.

And Tabor, if we go to the next slide, you’ll see what the OIG is. And the OIG really is the Office of Inspector General. And in this new tools for curbing waste and fraud, and if we just hit enter one more time, this testimony, what ended up happening was, the government stated that they were going to change the definition of fraud. You see, they see that fraud costs taxpayers tons, and tons, and tons of money.

But if you look real close, it says “Medicare and Medicaid fraud, waste and abuse.” That’s an important switch because in the past, especially the older doctors who graduated back in the Mercedes ’80s and the ’90s, we were always under the impression that it was fraud, it was basically because the patient didn’t come in and I billed them for visits they didn’t have, or build them for services they didn’t get. Well, that’s not what we’re talking about anymore.

So when we go to the next slide, we start to see that these rules have really, really, really changed. What we’ve found is that they decided to create new tools to prevent and detect fraud, waste, and abuse. Now if you keep reading this, you start to see fraud, waste, and abuse get combined totally into the conversation. So really what’s happened is that they started to treat waste and abuse the same as fraud. Now, it would make sense that waste and fraud would go together. I get that part. But abuse.

Now abuse can be seen in a couple different ways. Abuse can be seen in ways such as, if we look at the next slide, we start to see that it can be ways to protect the integrity of the system. So what I mean by integrity of the system is the dollars. So if we look at it in a way in which we’re trying to extract out abuse from fraud and waste, we really can’t because now the government is saying it’s a dollar thing. It’s a business decision. It’s not, “Should we treat them separately?” What they’re starting to say is, “We’re going to start treating them the same.”

Now the reason why I bring this up is because in the past I worked with a client who had an issue where he was billing AT modifier the entire time he saw the patient in a Medicare patient case. And the attorney general wanted to go ahead and charge the doctor with fraud. And this is one of the beginning cases where they started to test out AT modifier when the patient truly was in wellness care.

The doctor wasn’t aware. He was just trying to get the patient reimbursed. Even though he never took a penny because he was non par, the problem was is that the patient was truly in wellness care. The notes never really changed. And now the attorney general wanted to create a test case where he tried to charge the doctor with fraud, even though it was really abuse. So this whole process has changed over the last couple years. So if we know what the rules are, we can become empowered to be able to change.

Now, Tabor, go to the next slide. What I want people to understand is this, this issue that we’re going through here is something that’s really, really important, because it’s really, really about this next slide. And this is doctors who don’t understand things like, “Well, what am I doing here? What is this whole process?” And it’s all about goals. Now when we say goals, it’s important to understand that if you’re really, really big like this and, Tabor, if you click it one more time. You start to see that over time it takes change.

I had a friend who passed away, he was 41, from a heart attack. And I look like this and I go, “Oh, I’m going to die. I’m next.” Over the course of about two years or so, I was able to shed pretty close to 100 pounds. Now, did it happen overnight? No, it didn’t. And did I realize I needed to lose this the next day? Yes. But the next day, I didn’t lose anything. I was just planning on what to do. It’s the same thing with your office. What I don’t want you to do is I don’t want you to freak out and go, “Well, what am I doing? I’m really, really scared now because I don’t know what to do.” Now I see that we may have lost the PowerPoint.

Dr. Tabor: Oh, really?

Dr. Davila: Yeah. Just looking back at you here. So I’ll just go ahead and talk through the next slide, which is really just a picture of fat John and then two years later a skinny John, or skinnier John. The point being, that the compliance issues you have in your office are there. If you have them, let’s not be afraid to talk about them. Let’s say, “Okay. We have compliance issues.” But what we really need to do is understand that it takes time to fix them. We can’t get rid of them tomorrow.

In fact, if we gave you compliance things that you need to do. Perfect. Give me one more click to the picture. And as we make sure that we have this process in our head that we understand that it’s not going to be tomorrow. It takes time. It takes effort to be able to get it the right way. I work with a couple different practice management companies. And even within that process, it’s taken time to turn a big ship around. So the doctors that we have to deal with, please understand, it takes time.

So this is the perfect slide right here. So what’s the definition? Go back one more for me. The big issue we need to worry about here is what’s the definition? What are they using? How do I know that I need to change what I’m doing? So the definition I want to talk about really is the definition of medical necessity. And when I say that definition, what I want you to think about is have you ever seen it before? Have you ever read it before? Have you actually seen it in writing? Click to the next slide, Tabor.

What I’d laugh about this slide is, the next slide is really, have you ever seen it? And if you did, is it the Easter Bunny? And when I say the Easter Bunny, we always see a rabbit. We’ve never seen a rabbit lay eggs. Okay? So, Tabor, go forward one more slide for me. One more click. And when we see this bunny, it’s the definition of medical necessity. No one’s ever seen it before. So if we click one more time through that, what we’ll see is the definition of medical necessity as it’s written by Medicare. Now the reason why I say this definition is because it’s important to understand that the definition is the way things are going. This is what has changed over time. So the definition is this. The definition is, there you go. You with me now?

Dr. Tabor: Can you see it now?

Dr. Davila: Perfect. But I can see you now.

Dr. Tabor: Okay.

Dr. Davila: Okay. The patient must have a significant health problem in the form of a neuro- musculoskeletal condition necessitating treatment. And the manipulative services provider must have a direct therapeutic relationship to the patient’s condition. Now if we didn’t read the last line, that’s what we always thought it was. The patient has subluxation. We’re good. In fact, even though everyone’s out there now, especially EMR. We’ll talk a little about EMR as we go. Everyone’s talking about, “Oh, yeah. I have great part based notes,” or, “I have really compliant notes.”

Well, understand this. The first two lines here are what everyone’s built their EMR systems on. Now when I say that it’s because there’s really no way to check the last part, which is provide reasonable expectation of recovery or improvement of function. That’s the part that you have to work on.

You see, we always talk about “Well the patient has a chronic condition.” Well, actually it doesn’t really matter if they have a chronic condition or not because the first two lines we understand the patient has a condition. The last one is, provide reasonable expectation of recovery or improvement of function. So it’s not the fact that we’re getting paid to treat subluxations, it’s really we’re only getting paid from a third-party that treats subluxations if it improves the functional loss that’s related to it.

Now I know for a fact that a lot of you don’t really want to talk about pain with patients. And I don’t blame you. There’s no reason to. The reason why I say there’s no reason to is because if the insurance companies and Medicare are talking about functional loss, wouldn’t it make more sense to talk to our patients about how that subluxation and the pain related to it is causing the patient not to be able to walk upstairs, or not be able to go play with their kids. Not be able to play in the yard, or not be able to do work, or not be able to sleep, or not be able to drive.

What if we talked about those functional losses? Even though the underlying condition really is always still there. When I say underlying condition, I want you to understand that from a chiropractic think model, from a 33 chiropractic principle model, what we’re talking about here really is the fact that the patient is up against the 24 chiropractic principle. And that’s the limitation of matter. If the patient has a limitation of matter, then there’s nothing we can do to get them past it.

The only thing we can do is really not necessarily fix that limitation, but we can help them manage it better. And when we help them manage it, that means that we come up against the end of functional improvement. Even though the patient has arthritis, we’re not going to get rid of that bone spur. So there’s going to be an amount of functional loss that they have that we can’t improve past. Which means they have to live with a certain amount.

Now I understand that’s not really fair, and that’s not really what medical policies are. But understand the difference between chiropractic policy that we’re reading here and a medical doctor’s policy. The difference is that yes, we’re both playing with a ball and bat. The only difference is, we may be playing baseball, they’re playing cricket. The rules are different even though some of the tools are exactly the same.

So if we go to the next slide, Tabor. Really what I want you to understand is, with that definition in mind, what I want you to understand is what the definition works out as. And what I mean is, the definition like this. What is the abuse conversation in chiropractic?

Now if we click it one more time through there, what we’ll see is abuse in chiropractic really turns out to be when we build the entire case as active care. Like I said, when the doctor billed AT modifier the entire time, then we have a little bit of an issue. Now if you look at this graph as we go up on the left, that is the percent improvement of the functional loss. And on the bottom it’s time. Now the reason why I say this is because this is the way we should be looking at cases. Not the fact that the patient has subluxation, but how does that subluxation affect the patient’s ability of function?

Now if we go to the next slide, what we’ll see is the typical chiropractic case really should look like this. There’s active care and then there’s wellness care. What I want you to get out of your head is the conversation of insurance versus cash. Don’t want you to think that way. Is the patient insurance or the patient cash? The reason why don’t want you to think that way is because whether the patient is either active care or wellness care, you should treat them exactly the same. And I come into this conversation with this one specific reason.

I’m working with an attorney right now and I reviewed the doctor’s notes. And the doctor was a “wellness practitioner.” Now the patient comes in and says, “Oh, yeah. I have this pain down my leg.” The doctor’s like, “Oh, I don’t give appointments and I only do wellness care. This is what we do.” The patient signed, that has no idea what that means. And the doctor just said, “Come in when you need.” So the patient comes in, comes in, comes in for about a week and a half, two weeks. The patient’s getting worse.

The doctor’s basically saving their wellness patient and giving them wellness diagnosis codes, giving them wellness treatment codes. And the doctor thinks, “Well, I have no problem because basically the patient’s a self-pay patient. Therefore, no one’s ever going to ask.” Now what’s happened next is after two and a half weeks, patient’s not any better. They go to a second opinion. The second opinion sends them to the surgeon. And the patient needs a discectomy.

Now the question is did the doctor actually cause the disk problem? Probably not. But what does the doctor look like when the patient has an active condition with functional loss written down on their intake form, but they only diagnosed and treated it as a “wellness patient.” And mainly because after reading the affidavit that the patient, “Oh, the patient was cash. What do I care?” Well, you should care because the patient is either active care or wellness care. They’re not cash or insurance. That way your documentation should match this model. And when you’re looking forward to EMR systems, you should look and see if EMR systems have this ability to document the difference between active care and wellness care.

So if we go onto the next slide, what we’ll see is, if you didn’t bill that way, what we have to figure out is, well maybe we have tripped a wire. Now what’s that wire? What are some of those things that the insurance company’s looking for? So we go to the next slide, what we’ll see here is the fact that the patient, I’m sorry. The doctor and the doctor’s ability, to be seen by the insurance company, is really what the big issue is. So what the insurance companies do is they profile the doctor. And what I mean my profile is, they look at the information that you send them on a claim form. But some of you are going to say, “Well, I don’t get paid. What difference does it make?”

Well remember this little thing called HIPAA? HIPAA comes in when the patient signs for insurance. If the insurance company reimburses them, the patient’s already given HIPAA rights to the insurance company to get the documentation to prove that the patient should’ve been reimbursed. Now that means that your notes will be looked at. And that also means that your notes will be asked for. Now do you have to respond? Well, if you didn’t sign a contract you could say, “I didn’t sign a contract. I haven’t signed anything.”

But if the insurance company invokes HIPAA and you don’t respond, now we have a problem with the Office for Civil Rights. Because now they’re going to say you should respond. And I’ve seen a couple of recent issues where the Office for Civil Rights has handed out fines to doctors for not returning information over to insurance companies. So you’ve got to be very, very careful. That’s the reason why I say, regardless of who’s paying, treat them as active care versus wellness care.

Now when we go to the next slide, when you put the information on the claim form, this is what we’re telling them. This is the information, is that eight things on a claim form that the insurance company sees. That when they see it they’re like, “Oh, okay. I got you. Now I can put stuff together.” It’s the CPT code. We know the billing code you use. It’s the modifier that’s on there. We talked about AT or maybe GA. It’s also the frequency. How often are you seeing somebody? It’s also the duration. How long are you seeing somebody?

It’s the provider type. Chiropractor, PT, that all gets played into it. It’s the diagnosis. What type of case does the patient have? Where’s the service being done as far as how much they should pay? Whether or not they should be in an office procedure, out of office procedure. And also, the big one. If you’re going to circle one of them, if you’re going to take any notes today, it’s box 14. These are the big things, especially a Medicare claim. These are the big things that the carrier is going to look at and go, “Okay. Let’s put this all together.”

Now when I say put this all together, if we go to the next slide, what you’ll see is duration. It should be an equal severity to the diagnosis, which means your prognosis. So the duration of how long you’re actually seeing the patient between onset to the point which they get released into wellness care, should be equal to the diagnosis that you use. If we click it one more time, okay, here’s an example. If the patient has a diagnosis of sprain/strain, the length of treatment, if it lasts longer than expected, would be something that they would not like to see. So if it’s more than four to six weeks, they’re going to want to know why. That’s what I mean by duration versus severity of diagnosis.

Now if we go one more to the next slide, here’s another one. Duration of the case that lasts longer than 60 days from box 14. Now this is one of those issues where I’m on with the client and we’re on an administrative of law judge. And he says, “What’s the 60 day average?” And I have to know a little bit about Medicare. And I ask the question, “What’s the 60 day average?” And the judge turns around and says, “Well, your average case should last not longer than 60 days from the date of the first visit listed in box 14.”

Now you say, “Well, what about the patient if they need a longer time? If they’re a major severe condition?” Well, yeah. Okay, if that’s the case, then fine. That could be longer. They’re averaging. But what if your average case for a disk is 90 days? Is that going to be a problem? Well, remember, it’s not the fact that the patient is there an active care for the initial case. What they’re talking about is, if the patient comes back in three months later for another case, it’s usually just a flare-up of the initial condition. And that shouldn’t last more than 60 days. And every time you change box 14 and go back into active care, those dates, the amount of time that you’re in there, calendar days, actually get averaged.

So it’s important to know what your 60 day average is. You should pull some files and look and see over the course of the year how many times you took a patient back into active care. And then come up with the average. Let’s say the first time in active care was 90 days. And the second time they came in three months later for a flare-up, was really only two calendar weeks, or maybe 10 days total. So add 90 plus 10. That’s 100. Divided by 2 cases and now we have, divided by 2. Now we have 50. Fifty is less than 60. You probably wouldn’t trip a wire.

Now you’re going to say, “Where does 60 come from?” Remember when I talked a little bit about what the OIG and how they have their mitts in this whole thing? And how they have policy changes? Well, they came up with this when the OIG said, “Well, when we reviewed all these records, we found 100% of cases. We reviewed chiropractic cases in a 2009 OIG report. Really were not medically necessary 100% of the time, after 24 visits.” So 24 visits. Okay 24 visits. So 3 times a week for 8 weeks is 24. If you see them 3 times a week, then 3 times a week for a month is 12 visits. And 3 times a week for a second month is 24 visits. We’ll just go ahead and say on average 60 days. So that’s where that number comes from. So just understand when you look at your case reviews, you want to make sure how long you’re seeing the patient in active care.

So if you would go forward one more, there’s another thing you should look at. And if we click the button one more time, you’ll see, one more time for me. We go to the coin. We start to see that there’s a percentage of use. So the percentage of use of your code should really look like this. You should use your 98942 code 15% of the time. You should use, if you click one more time through there. Use your 98941 code 60% of the time. Thanks, Tabor. And then if we click through one more time, we see that we should use our 98940 code 25% of the time. And those are the percentages of the codes.

So if you think, “Well, I’m a full spine doctor. I bill what I adjust. And I bill three areas. So I do neck, middle back, and lower back. And I’m 100% 99401.” Well, that’s going to red flag you for someone to ask you for documentation. Now in the past, we heard, “I can’t bill on 98942. It’s bad.” Well, actually, it’s bad if you don’t because the percentages, they’re going to want to know the average case why. Now all these numbers came from the CERT doctors, director of CERT, when I was on the Medicare board. These numbers have basically stayed the same. Now when I say that, it’s really turned into, “Well, I’ll just go ahead and down code to a 98940. That way they all leave me alone.”

Well, do you realize if you’re billing 100 visits and you’re getting paid $20, and you’re billing all those visits. And 100 visits at $20 is obviously $2,000. When, in reality, you should bill 60 at 30 versus 40 at 20. Really what you’re losing is pretty close to a 15, 20% gap. So really, don’t turn into 100% 98940. You’re losing money. This is where your compliance rate should help you make more money if you’re just been painted into a corner because you don’t want to get audited. Now I understand part of that comes into, “Well, I don’t know if I have all of the documentation.” And that were going to get into in a few seconds. So getting the documentation part we can help you with. We have some things out there that can actually combine this process for you.

Now if we click one more time, you’ll see one of the other things is 98943. A couple of carriers I’ve worked for told me they’re looking for about 35% of the time using that code. So those are the percentage of uses. So understand this is what carriers are looking at. And this is what we’re telling them on a claim form. Every time they see this, this is what they get. And this is what they know about you. And I’ll give you a little of an example.

When I go out and I speak in front of large groups if I’m at Parker in Las Vegas or [inaudible 00:33:43] association. The big convention in Orlando. Or even small events, I’ll go up and I’ll speak in New Hampshire. The small groups, big groups, middle size groups, it doesn’t matter. I always have the same process. Before I go on stage, the first thing I do and the last thing I do is always go to the bathroom and check myself in the mirror.

Then you go, “Why would you do that?” Well, it’s very, very simple. The reason why I do that is because I want to know what I look like before I get on stage. I want to control the audience’s perception of me. Then you go, “What do you care what they think of you?” Well, I care because if I go out there and I have parsley in my teeth, my zipper’s down, my shoe’s untied, my shirt’s pulled out, they’re going to say, “What is this idiot out there doing? Why should I pay attention to him?”

It’s the same thing for you. You should know what your profile looks like. You should know what you look like when the insurance company looks at you. Because if you do, and you can, and you did, you would change what you do, that way you could bill the max amounts that you should be billing. And then in addition, stay out of trouble. It’s not about flying underneath the radar. Because let me guarantee you one thing, the doctor who bills 100% 98940, is going to get an audit letter just like everyone else. The only difference is, you’re going to have to go through the whole process of sending documentation and everything else to show that you should’ve been paid more money. They call that down coding. And this happens a lot.

I have upper cervical doctors, AO doctors that I work with. They only adjust [inaudible 00:35:13], so they’re 100% 98940. It’s important to know that because they get letters from Medicare too going, “How come you’re a 98940.” And they have to explain, “Well, actually because I’m upper cervical.” And they understand that. But it’s one of those things that even if you’re down coding, they want to know why you’re down coding, because the patient should get the max benefit possible. They’re going to check all that stuff. It’s important to know.

So Tabor, if you’d hit it one more time for me, we’ll see a little graph. This graph is really what everything should look like. Okay? And this graph really should be what a case should look like. But unfortunately, if we’re just billing the entire case to Medicare, that means that what we’re saying to the carrier is the patient hasn’t complained the entire time. Even though they do. They’re Medicare patients. They are. Why? The 24th chiropractic principle, limitation of matter. They have a complaint always. They always have a complaint.

So the way to be able to handle this, if we click through one more. There you go. What will end up happening is we have a problem where we have as the world turns. Now our billing patterns go on, and on, and on. We bill always because the patient has a complaint. Patient says pain, cha-ching, we ring the bell. Well, As the World Turns really, as the story goes, is really a story about the same 8 people in the last 50 years on ABC, NBC, CBS, whatever channel it’s on. And it goes on, and on, and on. People have died, come back to life. They’ve married, divorced, married six times, the whole thing. Have kids, now their kids are on there. The same story over and over again.

Now as the world turns means that it never ends. When the carrier gets your records and the patient has the complaint the entire time, the record never ends. It works like this, patient has pain, patient has pain, patient has pain. Day 10, patient has pain. Day 35, patient has pain. Day 95, patient has pain. Day 795, patient loves pain. All this stuff goes on, and on, and on. But the problem becomes, we get mad when a nurse says to us, “Excuse me, but don’t your patients ever get any better?” And that’s a big problem.

Now, Tabor, if you click it one more time, what I want you to see is really the way it should work. That graphic really should look like this. We should have at the beginning of the case, we’re talking about patient management here. We really should have the situation where we have active care and then wellness care. Our box 14 date takes place at the very beginning when we have the onset and we do what’s called a discharge summary. Or what’s the last two words of a book? The end. What’s at the end of an entire case?

Now when we get through this, you’ll see the discharge summary really tells us the patient is done and going into wellness care. Now when the patient comes back in the second time, then we go into active care. Now I apologize for the lack of a graphic there. We had a little bit of a conversion issue. But if we go click through one more time, you’ll see graphic-wise, what should be there is each time the patient comes in, that’s our 60 day rule that we’re talking about here. Active care, wellness care, we take those two cases and go from there.

So if you click through one more time, what I want you to know is, you have time. Now we’ve gone through some things about profiling and procedure and things like that. I want you to understand you have time. But no one’s bothered you, we have time to fix things. But I want you to understand something, you need, if you don’t have a system that can help you track these things. You don’t know the information we’ve talked about. You don’t know what your 60 day average is. If you don’t know you’re percentage of codes, if you don’t know what percentage of CPT codes you’re using, you don’t know the percentage of diagnosis codes or how long you’re at box 14, or any of those things. If you don’t know them, you’re just billing and getting paid, you need a practice system that can help you track those things. Okay?

In addition, you also need someone, if you have let’s say, a practice management company that helps you build your practice, in addition to that alone, you also need someone to help you keep up-to-date with all of this compliance stuff. Why do you think Parker College has hired me? Why do you think practice management companies have hired me to work with their clients? Or specific groups of doctors? Or actually, the newest, greatest for me is to work with doctors who own multiple clinics. To be able to help manage them. The reason why is because if we do that, we can help them know what they look like in advance. I can help them do that in advance. So if you need that kind of stuff, and I hope you do, what I want to do is this.

I want to make sure you understand, Tabor, if you’d go click through one more time, what I want to do is I want… I wanted to give this information tonight. In fact, the funny part is I’ve got nothing to sell you. I really don’t. If you want some help, you can call me. You can find me at You can email me, that’s cool. You notice I even give you my number. I really don’t care. I want you to get this information. What I want you to do is this, I want you to find out what are the four compliance questions you should ask your EMR or your EHR before you purchase something.

Now the reason I want you to ask this is because I get a lot of doctors that come to me and they’re not very happy what they’ve purchased. Now, the funny part is, I’m not sponsored by anybody. Okay? I don’t get paid by anybody. I don’t say, “This is the best one. This is not the best one.” What I do is I help doctors really customize their system. And what I want you to do is I want you to pick the one that’s best for you.

So what I did was I wrote a mini e-book and I want you to get it. This is a free gift, I want you to go download it. Tabor, if you’d click one more time for me, you’ll see in there. You can go get it at Genesis Chiropractic Software. Now I’m not backing them. I’m not telling them this is the best one. All I’m saying is if you go there, you can download the e-book and you can figure out exactly what it is you should get. And if you understand what you should be looking for, it may lead you one way, it may lead to another. Go there. Go to and on the right-hand side, the very top of the page you’ll see the word blog. Click on the blog, you’ll see this logo. Go there.

You can download the e-book. Easiest thing in the world to do. Help you understand exactly what it is. It will also help you to figure out things that you didn’t know issues you had. Do you have HIPAA issues? Do you have the right backup? Do you have the best way to be able to manage your billing procedures? All those things. So I want you to go there, download the e-book, take a look at it. Read it. And then if you need some information you can find me. No big deal. Tabor, I’ll go one more time. Just click for me one more time there. And I want you to see the last click of the box here.

In fact, if you click it one more time, you’ll see there’s a couple different ways you can get in touch with me. You can get me, you can find me at, first one is if you click second, third, and fourth time, you’ll see that you can find me on Twitter. I’m there all the time. You can just click through, yeah. Bring up the little pop-ups. You’ll see me on Twitter it’s @jdaviladc. You can find me there. If you going to Facebook, go to Helping Chiropractors do the Right Thing. Go there. I have a ton of information. I post things on a weekly basis. This is all free. For LinkedIn, it’s John Davila, DC. You can find me there also.

Just go there, especially on Facebook. I have a full history of things. I have almost two years worth of uploads, information on sequestration, information on EMR, EHR, all kinds of stuff. Procedures, penalties, all kinds of stuff that you want to read about. Or maybe you don’t want to read about, but just want to pull the headlines, that way you can stay up-to-date. The quickest way to get in touch with me is to follow me there, get all the information. I promised Tabor I’d keep it under 45 minutes. And with the start time, and everything else, I’m done. Tabor, it’s all yours.

Dr. Tabor: Thank you, Dr. Davila. All that info, I know we had a little bit of technical difficulties, but that info was absolutely priceless. I know I’ve got a lot of work to do. But I’m proud to know that Genesis Chiropractic Software works with guys like you that know what they’re doing. And I’m ready to implement the right things in my office. So I just want to thank you for being here and being on the call. I want to thank everybody else who’s on the call tonight and on the webinar. And I appreciate you, Dr. Davila. We will talk to you soon. Thank you.

And again, everybody go to Click on Blog and download Dr. Davila’s free mini e-book. And we’ll talk to you soon. Thanks, Dr. Davila.

Dr. Davila: Thanks. Take care, everybody.

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