Leveling the Playing Field – Chapter 6
How We Can Beat Them at Their
Own Game – Together
Leveling the Playing Field
When I was a kid, there was a Marvel comic book called Vultron. There were basically five superheroes who drove around in their own individual robotic lions. When they came up against a really formidable opponent, they were able to join all their lions together and form one gigantic warrior-shaped robot. Of course, working together, they were able to defeat the enemy that would have otherwise destroyed them individually. Today, my son watches Power Rangers. It’s basically the same concept.
Judo is a very well-known martial art. The main idea is to use your opponent’s aggression or momentum against them. So when the opponent swings at you, for example, you move out of the way at the same time you push them or throw them in the direction in which their momentum was already taking them.
Take these two concepts and smush them together. That’s how we beat them at their own game. We use their momentum and their own tactics, band together using a more powerful technology than we have individually, and destroy our formidable foe.
As we’ve been learning about insurance company strategies and tactics, I told you about the three components of any business:
We also discussed one very specific process they have: the audit.
We have dived into each component and seen how insurance companies are really just leveraging people, process, and technology from a totally different perspective or paradigm than we are.
- Insurance companies have unlimited cheap labor.
- Their highly paid staff only works on things that have a huge return on investment—audits, for example.
We have been doing the opposite. We’ve been paying our highest paid employees to call insurance companies, verify benefits, enter charges, enter EOBs, and dig into reports looking for claims to follow up on.
That’s gotta stop…if we wanna win.
All these things—missed visits, new patient checklists, re-signs, inventory management, credit card charges, documentation, coding, EOB posting, charge entries, claim submission, failed claim identification, secondary submission, patient statements, cash patient statements—they all matter.
And they are not going to go away. But we can certainly be more efficient and effective by using AI and automation.
Asking your awesome biller to do a good job with inferior technology is like sending them into a nuclear war with a stick.
Technology—that’s a big one. Remember, insurance companies leverage huge databases, automation, and AI, forcing your people to follow every manual process at a huge cost to you, both in terms of money and liability. Buying technology that addresses only one component of your practice while not addressing the big picture is a mistake.
Until 2004, there was no way to beat insurance companies at their game or even compete. No small practice could afford enterprise-level technology that could compete. Now there is a way.
The Internet changed everything. Here is the new solution—Genesis.
In 2004, we started a company built in the cloud. This was before the cloud was a thing to most doctors.
If we are going to win, we need a paradigm shift in how we think about our businesses and how we play the game.
It was a new approach, leveraging people, process, and technology to beat insurance companies at their own game, optimizing revenue, retention, and compliance in far less time, regardless of your cash/insurance payer mix. It is a new system and paradigm. It is smart, and it learns. It allows doctors to band together with one technology and use the insurance companies’ tactics against them.– Ultron and Judo, if you please. It has a life of its own. I named it GENESIS.
- With all of our clients submitting claims through one database, we could analyze data across all insurance companies all over the country—the same way insurance companies analyze us.
- The cloud provided more HIPAA compliance for patient data than traditional systems like ChiroTouch or Platinum (more on this later).
- We could now leverage AI and automation, just like the big boys, and alert doctors in real time about coding and compliance risks.
- Real-time transparency was achieved. Now a doctor could see exactly how many claims needed follow-up and in real-time accounts receivable numbers from anywhere there was an Internet connection. No more digging through reports, unless you have time for that sort of thing.
- Providers with more than one practice, or multi-specialty offices, could link them in the cloud and aggregate their own performance metrics.
- It was not just for insurance. We could also leverage automation to improve patient retention and staff efficiency, even for cash patients.
- Better technology development—on the fly—old systems are written in hieroglyphics. Cloud-based systems have the distinct advantage of being able to change the language as new ones are developed. It’s like building and refitting an airplane while it’s in the air.
Billing Network: The Network Effect
For the first time in the history of the profession, there was a billing network that any provider could join. When they joined, they were working with thousands of other users all over the country and contributing their data to the cause. (NOTE: In case you are wondering, no doctor could see another doctor’s data. Doctors maintain ownership of their own data.). It is a legal way to band together and fight back!
With patented technology, we now could leverage AI. It is the first step and goes hand-in-hand with automation.
AI helps find exceptions. These are critical items that affect your patient retention, your cash or insurance collections, and your compliance.
Here are some examples of exceptions—things AI can identify with zero work for you or your staff.
- A claim that is in the process of being created but is missing modifiers, linking, proper diagnosis codes, correct procedure codes
- A claim that is not supported by the daily note
- A visit that has not been billed out (even if it’s cash) or is missing a signed note
- A patient that does not have a future appointment or has a missed visit that needs to be rescheduled
- A pre-certification that has expired
- A patient with an expired care plan
- A patient who is coming in for a re-sign, a re-exam, or a future visit and needs something done prior to that visit
- A credit card on a patient’s account that has expired
- Inventory that is low and needs to be reordered
- A claim that is missing critical data on the claim or associated patient account
- A claim that was created by a specific provider in your office that is in network, where another provider is not
- A claim received by the insurance company
- A claim that was received but no EOB came back
- A claim that was fully paid but needs to be submitted to secondary
- A claim where one code was paid, another code was denied, and a third was slightly underpaid
- A claim that was fully processed but still has a patient balance
- A claim with a patient balance where there is a credit on the patient’s account
- Payer-specific exceptions
- Provider-specific exceptions
- Specialty-specific exceptions
- Region of the US exceptions
- One insurance carrier in one state changed coding requirements.
- A diagnosis code or procedure code has a high rate of denial.
- Allowable rate trends for certain carriers general or specific to your office.
Automation is key to beating insurance companies. They have it; why shouldn’t we?
A lot of technologies brag about their reports. That’s great. I would say that Genesis has the best reports in the industry by far. But so what?
If you look at all the expectations above, each one is really a report. Do you or your staff have time to look at every one of these every day, let alone address each item? I would argue that you do not even have time to look at one of them or even determine if anything was done about each and every exception every day.
There are three very important steps to managing any business or process.
- Quantify the work that needs to be completed.
- Delegate the work to someone who knows how to do it and wants to do it.
- Verify that the work was done each and every day.
Numbers 1 and 2 are relatively easy to do. You make your checklists, you hand them to staff members, you determine who is responsible for each one, and you periodically train your staff on them.
The management paradox
Where we all fall short is Step 3—verifying that the work was finished. As a chiropractor, you wear two hats. You are a business owner/manager, and you are an employee in the business. Being an effective manager and employee at the same time is (was) virtually impossible.
It is like asking you to be the conductor of an orchestra and the violin player in that orchestra at the same time. How could you be effective at listening to what everyone else is doing and being excellent at your own craft? It’s nearly impossible—until now.
But clearly a system that is smart enough to find every exception
and stick them in reports is not enough.