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Coffee with Kats Maintenance Care

insurance Jan 06, 2019

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Mike: Hi everybody I'm Mike Perusich, Dave Kats and Patrick Hammond with Kats Cnsultants. Thanks for joining us today. I thought something we ought to really talk about is maintenance care, and the fact that maintenance care is typically not covered by insurance especially Medicare. They don't cover it at all. Most of these companies have very specific rules. Let's throw that out on the table.

Dave: One thing with maintenance is doctors think if I quit charging insurance and have the patient pay for maintenance, all my patients, all my maintenance patients are going to quit but I've seen this for 30 years and that is absolutely not true. When you convert somebody from insurance paying to once a month maintenance, they're going to stay with you in 95% of the case.

Mike: I can give you a great example of that and that's my practice. I converted my entire practice from an insurance-based practice to a cash maintenance practice, and now my patients are begging me to come in once a week or even two or three times a month. There's definitely a fallacy there that you're going to run patients out. But, Patrick, how you handle some of your maintenance patients?

Patrick: I'm a very insurance favored practice but it's amazing like Dr. Kats was saying, once those patients, once you get them stretched out to two weeks just say, hey, what we'd suggest is you do once a month, your insurance is not going to pay for that, we have a plan called ChiroHealthUSA, it turns them over to a cash service and they're always more than happy to just jump on board and follow up with the care. They understand the importance of it but more importantly if this feels good why wouldn't I continue with this?

Mike: Yes, you bring up a great point. A program like ChiroHealthUSA, we'll call it CHUSA for short, ChiroHealthUSA can really help your practice build a legal compliant cash fee schedule. CHUSA really is just a third party administrator for your cash based plan and it allows you to give that flexibility to the patients to give them a nice fee schedule on the cash side that they can afford.

Dave: One thing I think we almost forgot to say at the beginning of this is, if a patient is on maintenance, insurance doesn't cover maintenance so if you're sending in the insurance you're really doing something you probably shouldn't be doing. Not only you call it active care when it's really maintenance that's really wrong. That's really a bad thing to do and illegal to do really. You've got to get to the place.

By the way, it invites an audit like nothing else. If you don't have anybody ever that isn't under maintenance you can just about bet that sometimes you're going to get the audit and they're going to see if you are releasing people. I know some doctors that see people 36 and 38 times and never release them and that just can't happen. They're inviting an audit.

Mike: We can look at Medicare and really understand a little bit better about the rules on maintenance. Medicare says, when there's no reasonable expectation for improvement with the patient and improvement is based on functional improvement, when there's no longer any reasonable expectation for improvement they're supposed to be discharged to maintenance.

Is chiropractic maintenance care covered by Medicare? No, it's not and so you have the patient sign the ABN form, they choose whether or not they want to pay for the service but you know it's not going to be covered, you report it to the patient, you follow your compliance guidelines and now the patient's cash and you put the different modifier on your billing to signify that to Medicare.

We can follow those same rules with general insurance. If there's no longer any reasonable expectation for improvement, in other words your outcome assessment disability questionnaires have stabilized or are below, in most instances, 20% then you probably have a patient that needs to go to maintenance. Follow your rules on maintenance, build a compliant practice, your patients will love you for it, you'll not throw up red flags for audits and you'll be in good shape. I'm Mike Perusich, Dave Kats, Patrick Hammond with Kats Consultants. Thanks for listening.

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