153: The Medical Necessity Trap

The Medical Necessity Trap 

Dr Michael Perusich: What is the medical necessity trap? 

Dr Michael Perusich:  Hi everybody. Welcome to the KC CHIROpulse Podcast brought to you by Kats Consultants helping doctors keep their pulse on success. I'm your host Dr. Michael Perusich and I'm by myself today because I really want to dig into this whole idea of medical necessity and what the Trap is all about. And I apologize now I get kind of passionate about this conversation because I see a lot of doctors in our profession really kind of missing the boat on this and maybe I get a little passionate because I'm also drinking coffee. I have my Keep Calm Cup today.

Dr Michael Perusich: So medical necessity. What does that mean? this is what insurance companies pay for they pay for medically necessary care and hopefully everybody knows that and what is medically necessary care. it meets the confines of whatever the policies are that the insurance company has in place. So every year those policies change you need to be going and reading those and keeping updated on those policies. And sometimes they'll change things on you a little bit they'll like for example several years ago. There was one of the insurance companies stopped paying for 97014 muscle stem and made it investigational and put it a hundred percent to Patient responsibility. And so a lot of doctors just quit billing it they're still doing it. But why because that's the opposite side. There's clinically appropriate care that patients can and should be paying for so we've got to make a differentiation there.

Dr Michael Perusich: And we got to make a differentiation not only in our notes our record keeping and our diagnosis, but we need to make that differentiation with patients need to understand this because patients need to be invested in their care plan. You shouldn't be doing things that you're not getting paid for. that's just not fair to you and really if the patients understand it they would agree that it's not fair to you. So I want to drill down on this a little bit because doctors are kind of starting to get in trouble for not really following the rules on medical necessity so Medical necessity is born out of having a diagnosis on a patient which requires an evaluation. Okay, you have to have an evaluation to get to a diagnosis to get to a treatment plan.

Dr Michael Perusich: And it's inside of there that medical necessity happens. So if you're evaluating a patient and you determine that they have sciatica and disc degeneration and muscle spasms and muscle weakness and radiculopathy and whatever you guys know what the diagnoses are. And from there you determine that the patient needs 56 visits. Is that going to be medically necessary? Probably not because it's so far out of the confines of the norm. that they're probably going to frown on that. So part of the Care would be medically necessary. But how much of the charismatically necessary and this is where you have to understand what the policies are. You're so crazy thing a lot of these insurance companies put out directives that tell you exactly

Dr Michael Perusich: What their policies are until how long you should treat somebody they tell you exactly? What you're diagnosis is and how that relates back to the number of visits you get and this is where the Trap happens. So if you're billing an insurance company and you haven't started care off with showing the insurance company that you've done an exam and how do we show the insurance company that we've done an exam? We build a 99211 to a 215 really? It's probably 99212 99213. Those are the primary exam codes, but that's how the insurance company can tell you’ve done an evaluation far deeper than just palpation. and range of motion you've done a full-blown meets the confines of the diagnosis in the confines of the E&M codes.  I  need a sip of coffee.

Dr Michael Perusich: it meets the definition of the E/M codes. And you've got a diagnosis that matches up to that. So' diagnosis. You treatment plan all tells the story. So for example, if you have a patient that comes in and has a subluxation and a sprain strain injury. Let's say in the low back. Okay, and that's your diagnosis a subluxation and a sprain strain injury. Okay, does that get 24 visits? No, probably not.

00:05:00

Dr Michael Perusich: Does it get four to six visits? Yeah, probably so this is where you have to be careful because if you're submitting spraying strain and a subluxation and your billing visit number 18 on this patient, you might be throwing up some red flags in the insurance company might say let's go audit those records. Let's request those records and see what they're doing. Be a reason why you should still be treating the patient. Yes. I'm not saying there's not but What we do sometimes is we inadvertently put ourselves on the radar screen with the insurance companies. That's the Trap is we want to try to avoid that as much as we can because you let me ask you a question are audits fun.

Dr Michael Perusich: No, are they time-consuming? Yes, by the time you get all those records and things put together and review them for completeness ETC and of course you never change a note along the way you can do an addendum, but you don't change a note. But making sure that all the t's and are crossed and eyes are dotted and your signatures on there and the dates are good. Once you do all that you've spent a lot of time to do that. on one case is gonna be a lot of time. No, but we've seen instances where insurance companies are requesting 20-40 cases at a time. Holy cow. That's a Time trap right there let alone. A fearful issue because once they go through them if they find something wrong what happens? they want money back.

Dr Michael Perusich: So the insurance companies that in my opinion actually done us a favor. They've defined necessary So simplest way to explain it medically necessary is Clinically appropriate as Wellness care maintenance care. those kind of things are clinically appropriate as the doctor in clinically appropriate land get to determine by your expertise and education and your evaluation whether the patient is in medically necessary needs to be a medically necessary care or if they're in clinically appropriate care you get this decide that But far too often, we're just trying to shove all the patients into medically necessary. So their insurance company will pay for it because we want the patient to only have their insurance company paying for care. Why?

Dr Michael Perusich: Let's educate our patients on the idea of clinically appropriate care. And those of you that have Wellness clinics and you're really good at moving patients over to maintenance and they're paying cash for Bravo. You've also figured out something else. In clinically appropriate land you have control over your fees and your profits. Okay, we're gonna hold off on that for just a second. We need to get a word of from our sponsor in here, And when it come back and I want to talk a little bit more about what the insurance companies are watching for. I want to talk a little bit more about proving medical necessity. And I want to talk about the diagnosis changing game that we often do to keep patients on insurance. So hang tight will be right back.

Dr Michael Perusich: All right everybody. Welcome back to the KC care reports podcast brought to you by cats Consultants. We're talking about the medical necessity and this is a real thing. The insurance companies are watching What are they watching? they're watching to see how long you're billing them on a diagnosis set. And because they know how long you should be dieting how long you should be submitting your claims for every diagnosis combination that you can come up with. They've spent years modeling this information when we send in claims and they all have this data. And so they're also looking to see if you've just changed the diagnosis, but you didn't Bill an exam code.

Dr Michael Perusich: How can you change a diagnosis unless you're downgrading a diagnosis? You might be able to do it. Then you might be able to go from a three or four region diagnosis to a two region diagnosis that for example and have that documented in your notes that those areas have improved and we're no longer treating them or though those. Have improved and they're no longer clinically appropriate to treat. Then you might be able to do that. But if you're just changing the diagnosis to try to keep the patient after 18 visits to try to keep them on insurance to get another 18. That's a red flag that at some point is probably going to get A records request at best it might not be a full-blown audit. Okay might not be We don't know what the triggers are fully to get audited. we have a pretty good idea and trust me. I've seen it happen enough with clients that we have a pretty good idea when those are going to happen.

00:10:00

Dr Michael Perusich: We have a better idea of how to avoid it. And we avoid it by educating our patients on the difference between medically necessary and clinically appropriate appropriate and always proving our diagnosis always proving medical necessity. We do that by doing periodic exams. Is the patient still in need of care that is billed to insurance companies. How do you do that progress exam six visits 10 visits, whatever. the industry standard is every six visits or every 30 days in care whichever comes first. Okay, but be careful with the 30-day cycle because if you're on month five. And you're still treating? Because you're on the 30 day cycle that could be dangerous at some point. The patient probably needed to be discharged to clinically appropriate care or maintenance care.

Dr Michael Perusich: So really keep an eye on this and make sure that you're doing your exams. We need to be doing the So initial exam Bill the EM Progress exam build the enem code and I know some of you're sitting out there saying They don't pay for in my state. So bill it and have the patient pay for it if it's not going to Patient responsibility.

Dr Michael Perusich: Yes, then you need our help to figure out how to make that work because regardless anytime you're at risk of getting your records requested by an insurance company, even if they're not paying for something and you haven't built it. You should at least have done it. And have the documentation to show. Hey, an exam insurance company doesn't pay for it. But we have the documentation that we're still in acute care. So don't system don't shortcut your exams are what help you prove medical necessity also get good at discharging patients to clinically appropriate care. There is a point in time. Where the patient is not going to see any further progress? On that diagnosis and they need to be moved over to maintenance care. Now there are some tricks they're not really tricks.

Dr Michael Perusich: There's some great communication strategies that you can use to help patients understand the value in the benefit of that and they work fantastically and if you tee up that patient communication, right? They're ready to go into maintenance. They're ready to pay you cash. when I say, they're gonna pay you cash. How amazing does that sound? I mean, give me a heck. Yeah, because that's where the Panacea of practice is when you can get your patience over to cash. And you have control over care and you have control over your income and you have control over your profits.

Dr Michael Perusich: That's where practice really happens because on the other side. Yes, you want your patience to be able to use their insurance to a point where it's compliant. You've got to train them that you can't use it forever. You've got to train them that just because they get 30 visits a year or whatever. It might be that they don't get all that on one diagnosis necessarily unless they're so bad. There is so much acute distress that you can document the need for that many visits. So you just really got to think about how you put your treatment plans together how you're proving medical necessity how you're driving that patient down the path of understanding what part of care is the insurance company's responsibility and what part of care Is their responsibility and again if you're messaging is correct?

Dr Michael Perusich: Then it If you're messaging isn't correct. Then your patients are going to drop out of care and you're going to be under this constant barrage of needing more and more new patients all the time to replace them. What we want to do is we want to build a practice right? We want to build the practice. But if you're constantly on the treadmill of new patients because everybody's dropping out because you're not differentiating medically necessary between clinically appropriate care. Then you're shooting yourself in the foot and you're creating a practice model that is really hard to sustain.

Dr Michael Perusich: So I'm gonna get off my high horse about this a little bit. I've probably beat this to death, but I think this is just incredibly appropriate topic and we're kind of here beginning of the year. these are great times to make some procedural changes in your practice. These are great times to Tell patients. Hey things have changed and I'm getting my clinic into clients and I'm bringing you along with that. And so we're gonna have a little conversation about how this Patients understand that Healthcare changes. They know the rules change. They know that we have all kinds of compliance things that we have to manage.

00:15:00

Dr Michael Perusich: coffee, so make sure that you're really drilling down on some good procedures To get yourself over the hump. Of what may be a bad habit that you've created and it's okay. We see a lot of doctors have done this and it's okay. It's just because you don't always understand necessarily that it's happening Number two, you don't realize that over here on that cash side of the practice practice the clinically appropriate side how great it is over here because a lot of us think patients aren't going to do that. They're just going to drop out of care. And as long as we have that attitude they will so these are cats Consultants that we help doctors. Do these are the kind of things as strategies.

Dr Michael Perusich: That we help doctors put in place so that their practices can run more smoothly and they actually have controlled scalable growth and how great is that to be able to do that? How great would it be to lock the door and turn the lights at night walk out of the clinic and go home and go whoo, that was a big busy day, but what I can sleep tonight because I know my practice is compliant.

Dr Michael Perusich: I know I'm meeting the confines of medical necessity and I know I'm putting some controls in place where patients want to retain in practice. They understand retaining and practice and they understand the value of paying me cash for those services. 

 

Dr Michael Perusich:  So creating that mix in your practices is really important. This is one of the many things that we do at Kats Consultants is we really help doctors drill down on these kind of things. So if you haven't done so yet go to cats consultants.com check out what we do. Hey, if you want to do a breakthrough call with us, we do these for free. If you want to do a breakthrough call with us jump on my schedule. And let's just talk about your practice. Let's talk about where you're at. Tell me your list of pain points. And let's see how cats Consultants might be able to plug in. We can't help everybody, but we might be able to plug in and help you with some of these things. So if you're ready to find the Path to Profit and the path to Mastery and Chiropractic

Dr Michael Perusich: Check us out and dive into what we're doing with people with doctors out there. We got a lot of free downloads and things on our website too. So check those out as well - and I can see the sun shining in on me today. So it's a good day here at Kats. All right everybody I'm checking out. Thanks for Be sure to subscribe to the podcast and we appreciate you listening from all of us here at Kats Consultants - have an amazing day.