Significant changes occurred this year to DC E/M billing and coding that can improve your healthcare reimbursement methods and results…
I HAD RECEIVED THE QUESTION, “About 9-12 months prior to the COVID-19 pandemic, I noticed my insurance reimbursements gradually decreasing. I provide high-quality care and help a lot of patients get better, however, I am not getting paid what I deserve. This becomes especially challenging knowing that I will not get paid more when I spend extra time with patients. I have also noticed that my cash patients are not paying their balances in a timely fashion and we need to send statements in the mail. Can you provide me with a few good strategies to remove these reimbursement roadblocks?” The answer? Yes. Here is part 2 on more ways to overcome these obstacles and improve your healthcare reimbursement methods:
Analyze data: CPV, PVA, PCA
What is your Cost Per Visit (CPV)? This amount is calculated by dividing your monthly overhead expenses (e.g., rent, payroll, equipment leases, malpractice, taxes) by the number of adjustments per month. Example: If your monthly overhead is $10,000 and you see 400 adjustments/month (100/week), then your CPV is $25.
Next is Patient Visit Average (PVA). This amount is calculated by dividing the number of adjustments per month by the amount of new patients per month. Example: If you see 600 adjustments/month (150/week) and 20 new patients per month, then your PVA is 30.
Next is Patient Case Average (PCA). This amount is calculated by dividing the amount of revenue per month by the amount of new patients per month. Example: If your monthly revenue is $50,000 and you see 20 new patients per month, then your PCA is $2,500.
Another data exercise in regard to healthcare reimbursement methods is to figure out how much reimbursement you’re receiving per visit per health plan. Here’s how to do it:
- Pull the last 25 patients that have come in with Health Plan A for chiropractic care
- Calculate how many total visits all of these 25 patients received
- Calculate the total amount of money collected for all 25 patients
- Divide the total amount collected by the number of total visits to get the amount collected per visit
- Example: 25 patients received a total of 100 visits. The total amount collected for all 100 visits is $3,000. Then $3,000 divided by 100 visits = $30 collected per visit.
Analyze these numbers with a practice management consultant and see where you stand amongst your peers.
Healthcare reimbursement methods and EOBs
Analyze your insurance explanation of benefits (EOBs). There are five “amounts” that appear on EOBs. They are the charged amount, allowed amount, write-off amount, patient responsible amount and the amount paid to the provider.
Billing managers should meet with the business owner 3-4 times per year and do a concentrated dive into these amounts to ensure that they are being processed properly. We have noticed providers leaving a lot of money “on the table” when this isn’t made a priority or doesn’t get analyzed properly.
Office billing managers have probably heard of CPT code bundling. This is a process that many insurance companies use to deny claims based on the Correct Coding Initiative Edits (CCI edits). A classic example is CMT (9894X) and Manual Therapy (97140). If both of these procedures are performed in the same anatomic site, the CCI edits kick in and “bundle” the codes and only reimburse for 9894X.
ICD-10 bundling is another process that health plans may use to deny claims based on the two types of “excludes notes” within the official ICD-10 guidelines. Each of these excludes notes have different definitions for use but they are both similar in that they indicate that codes excluded from each other are independent of each other.
Excludes 1 is used when two conditions cannot occur together. An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above in the Excludes 1 note. Example: M54.5 (low back pain) has an Excludes 1 indicator with M54.41 (sciatica with low back pain, right side). Therefore, do not report both codes. If both codes are submitted a denial will probably occur. Other examples include M62.- (muscle disorders) with M79.1- (myalgia), and M79.2 (neuritis) has an Excludes 1 indicator with M79.7 (fibromyalgia).
Excludes 2 indicates that the condition excluded is not part of the condition and a patient may have both conditions at the same time. When an Excludes 2 note appears under a code it is acceptable to use both the code and the excluded code together.
Fee schedules and authorization
There are pros and cons to being an “in-network” provider. One of the benefits is the ability to analyze the participating provider reimbursable amounts per code.
Some providers are in-network with many plans and if precise tracking of payable amounts does not occur, it will stall the growth of a practice. One of the negatives of being in-network with multiple plans is that it’s hard to track and this causes frustration in the billing department. Some offices get “stuck” billing for limited procedures because they didn’t know other services were available for coverage or only bill for passive modalities (e.g., hot pack, e-stim). They do not do a deep dive into the fee schedules and do not realize all the services that may be authorized within the plan.
Also make sure to be collecting the proper co-pay amounts. If you do not collect the proper amounts and the patient does not return for care, you then may have to “chase” after the patient by sending statements in the mail. It’s important to get patients to understand their financial responsibility.
Analyze the data and track how much should be paid per visit while the patient is actively being treated. While some offices may find it easier to simply mail patient statements, there are usually hidden costs associated with this. It may cost between $5-$10 per patient to send and process each statement by mail, plus once you mail a statement you are decreasing your chances of receiving payment. Studies show that the chance of collecting from a patient drops almost 20% as soon as the patient becomes inactive. Do your best to track and analyze your fee schedules. Start with a simple Excel spreadsheet and enter the name of the plan and the payable amounts per service provided along with the deductible and co-pay amounts per group plan.
Fighting back
After analyzing data, you may come to the realization that some plans are not paying your claims properly and in accordance with the fee schedule. And no matter how much you appeal, they cannot give you a straight answer or be logical with their reason for the aberration in payable amounts. This can be very frustrating.
Here are a few steps to consider:
- Demand to speak to a supervisor and show them how the claims are being processed incorrectly — they must take action and try to help you, especially because you’re a participating provider.
- Get patients involved, especially because it may cause a financial burden on them. They can call and demand an answer to this situation. Health plans are more likely to take action when patients complain versus the health care provider.
- Contact your state chiropractic association and make them aware of this. Hopefully your state association dues include an attorney to speak to about this situation.
- You may be able to file a formal complaint with your state insurance commissioner.
- Contact your own attorney and send a letter to the health plan demanding a resolution.
- Contact the American Chiropractic Association or the International Chiropractors Association and make them aware of this.
Also, I recommend that you hold on to the pre- and post-EOBs that show unusual payment patterns — this could be used to re-submit claims for proper reimbursement.
Fee confusion and resolution
All patients should be aware of your normal fees, especially if you are providing discounts. Some give discounts without advising patients of the practice’s normal fees and this can cause “sticker shock.” Patient education is important now more than ever. Address medically necessary and wellness care during the report of findings. In my opinion, all patients can be categorized into either active care or wellness/maintenance care. During active care or active treatment the patient has pain, restricted motion, inability to perform normal daily activities, muscle spasm, sprains/strains and decreased functional performance. Active care/active treatment is typically covered by health insurance because it is considered “medically necessary.”
On the other hand, during wellness care, the patient has very little or no pain, has good motion and can perform most/all normal daily activities. Once a patient has plateaued or reached maximum therapeutic improvement, this is considered maintenance care. Wellness and maintenance care is not typically covered by health insurance because it is considered “not medically necessary.” Make sure the patient has a clear understating of the difference and you will see improvement in your healthcare reimbursement methods and results.
MARTY KOTLAR, DC, CPCO, CBCS, is the president of Target Coding. Over the last 12 years he has helped hundreds of chiropractors and integrated practices with compliance as it relates to billing, coding, documentation, Medicare and HIPAA. He is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 800-270-7044, TargetCoding.com, or at drkotlar@targetcoding.com.
