Academy of Chiropractic

Quickie Podcast 1292
Compliance and Insurance 67 CA

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

Handling Insurance Audits

Guest: Yes, doctor, I received a, letter from blue cross blue shield asking me to contact their patient education or provider education department on my overutilization. I'm not part of blue cross blue shield, but they're definitely sending out these letters. I don't use UC nine eight, nine, four three, maybe 10% of the time I'm using nine, eight, nine 41. Most of the time is nine eight, nine 42. So we're not having many getting to them unless they're out of network. So my question is how do I handle such letters or they're asking to respond to it? Do I even read it Right?

Dr. Studin: This is multifactorial and understanding what's happening. Blue cross blue shield as a rule does not have a provider education component. They have SIU special investigative unit, which this appears to fall under, but they're putting it under the guise of an educational unit. You know what SIU is? Yes, correct. That's their investing, that's it. And it's a form letter, but you're on their radar screen. That's just the bottom line. Now that all comes down to your documentation. So before we get to that, which we're billing in a moment, you don't communicate with them. You don't talk to them. Your healthcare lawyer, does you never talked to an insurance company at any level of an investigation directly. You do it through your attorney. So one, do you have a healthcare lawyer? Not a PI lawyer, not a corporate lawyer,  not a family lawyer, but a healthcare lawyer, 

Guest: Malpractice, 

Dr. Studin: No Malpractice. You need a healthcare lawyer. So when we're done, I'm going to give you a couple of names of other doctors that I work with in your region. And they'll direct you to a healthcare lawyer. And the healthcare lawyer is going to call them and say, I'm calling on behalf of my client. What do you really want? Because you sent the form letter suggesting he used codes, which he has never used. And what the hell do you do? What do you really want? And it's at that point in time, somebody asked for your documentation. Now the question is for every area you touch touch to the facts. You need a symptom, a clinical finding, and the diagnosis for every area you touch. So even if you did three areas, four areas, five areas, you need those three things. So the first question you have to ask yourself and I can't answer them is, do you have them? Secondly, I have no problems looking at your documents to see if you have them at the, see if you've documented accordingly. We've done a compliance review, correct? 

Guest: Yes. 

Dr. Studin: Okay. And are all those areas cleaned up or is this before we first started that they're going back historically, I've been always pretty good to learn this. I've been doing this long time. Pretty good on the symptom clinical finding related to diagnosis. I rarely. Not related to diagnosis synthetical symptom clinical findings diagnosis related to the area of touch. Correct? 

Guest: Correct. I'm pretty good at that.

Dr. Studin: Excellent. Now, let me tell you about the technology. We create a called Symverta and you should have read about it by now heard about it. One of the podcasts we've created an x-ray digitizing program, you've heard of x-ray digitizing to look for laxity ligament. And there's a lot of companies out there that do that. We happen to do a better or the best in the industry because no one prorates it other than us, but there's another component to it, which is a biomechanical component. And we are working extremely hard in being on the cutting edge of the entire world and the literature and putting stuff in there. No one's ever done. So we are, you know, it's really cool. But one of the things that gives you is it gives you an actual blueprint of vertebra misalignment and gives you a blueprint and a demonstrably validation of the diagnosis, segmentally.

And you actually re x-ray your patient probably at the 90 day mark and that's every three months. So when you start treating, I honestly, I would x-ray my patient every two months, because there is no side effect of a diagnostic x-ray it just doesn't exist. Um, but what it does is it gives you a blueprint of where you're treating demonstrably. The carriers can never say boo, because now you have a demonstrable region to adjust two areas, three areas, you know, I can't do pelvis on this, but you have a demonstrably areas to adjust and pelvis is these document. So, but that's the key is to make you Bulletproof. And when we've had doctors in the past week and they send them, here's why we adjusted. And a big arrow was, you know, the segment being not only rotated, but angular, deviated roll, pass pathology, you know, it's like up yours carrier.

And then they go, they have to go away because you now have a, the key is demonstrable because even though you've documented causality bodily injury, persistent functional was the next thing the carriers are doing is coming up with predetermined treatment plans. And I've been living that for the past month, morning, noon, and night. In fact, I hired last Friday, a health care criminal defense lawyer, 500 bucks an hour. We spent a full half a day just discussing how the carriers come up with these pre-determined treatment plans and patterns. So what they're going to say on this one particular patient, it seems appropriate, but if you aggregate all the patients over an eight year period of time, six years, 10 years, you're going to see 94% of the patients have the same problems, which means it's a predetermined treatment plan. And by the way, you're supposed to have a pretty treatment plan.

Just like if somebody walks in with a brain tumor, the treatment plan is to get rid of that brain tumor. You know, it's predetermined. Those are called protocols in industry. So you've got to take your level of demonstrably verification to the next level. Technology will help make you more Bulletproof. So that's for tomorrow, however, for yesterday, okay, you need to get a healthcare lawyer, call the insurance companies and say you sent the form letter. My client never, ever, ever wants that. A nine, eight, nine, two, three. I'm not responding to this form letter. If you have a specific issue, you let us know and we'll respond to it with whatever you need. And you're going to pay a healthcare lawyer between four and $550 an hour for this. It's just part of the course of doing business. You do not talk to the carriers ever, ever directly ever be very clear about that. It's part of the cost of doing business. 

Guest: Appreciate it, doctor. Thank you very much. Those names. I'd appreciate it. 

Dr. Studin: I'm going to hang up. I'm going to call you right back. Okay. Thank you. Bye bye.

 

PLEASE TAKE FURTHER NOTICE: CONFIDENTIALITY AND PROPRIETARY INFORMATION NOTICE:  This email including attachments is covered by the Electronic Communications Privacy Act (18 U.S.C. 2510-2521) and contains confidential information belonging to the sender.  Nothing contained in this message or in any attachment shall constitute an Electronic Signature or be given legal effect under 44 U.S.C. 3504 Sec. 1707.  The information is intended only for the use of the individual or entity to which it is addressed.  If the recipient of this message is not the intended recipient, you are at this moment notified that any unauthorized disclosure, dissemination, distribution or reproduction of this message or any attachments of this communications is strictly prohibited and may be unlawful.  If this communication has been received in error, please notify the sender immediately by return email, and delete or destroy this and all copies of this message and all attachments.