Kicking You While You’re Down – Chapter 4

Chapter 4
Kicking You While You’re Down

Recap

1. We know how and why insurance companies rig the system and make all the rules.
2. We know the rules and tactics they use to look good in the patient’s eyes and still make tons of money.

What’s next? How can they tighten the screws just a little more before they deliver the fatal blow?

As if all the leverage they have and all the rules they’ve made weren’t bad enough, they just keep swinging. In this chapter, we are going to look at a few more tactics that fly under your radar. 

What are they doing with all of that money? Investing in their business, of course. Specifically:

1. People – much cheaper people
2. Processes
3. Technology
4. The Audit

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1. 1. People – Cheap Workers

When it comes time for workers, they outsource. There are literally unlimited resources in India, the Philippines, and many other emerging countries.

1. 1. It comes down to this. You have to call them and pay US dollars, say $15 per hour, and they pay their workers less than $1 per hour.
   2. You are one person; they have unlimited people. 

2. 2. Process

Every manual step you take costs you money. They want to make this process very expensive for you, and therefore manual.

Your manual steps

2. 2. 1. Benefit verifications
      2. Pre-certifications
      3. Hunting and pecking for codes, modifiers, linking, ordering, units, and so on
      4. Documenting every visit, hoping you’re getting it right
      5. Submitting the claim to a clearing house (God forbid that you would send them by paper)
      6. Correcting claims in the clearing house before they get sent
      7. Posting EOB
      8. Finding unpaid claims, underpayments, and denials in aging reports
      9. Submitting to secondary payers
      10. Calling insurance companies for denials, underpayments, benefit verifications, pre-certifications
      11. Submitting supporting medical necessity documentation and appeals
      12. Resubmitting claims
      13. Collecting patient balances

Their manual steps

2. 1. Answer the phone when you call on a claim, benefit verification, or pre-certification
   2. Auditing you
3. Technology and Automation—How Can You Compete?
4. What technology are insurance companies investing in?
   1. They build a massive database in the cloud, collecting data across all chiropractors and other physicians.
   2. Their AI looks for trends and finds outliers for
      1. coding
      2. documentation
      3. follow-up
   3. The AI then automates the rest based on what it is learning. They automate:
      1. claim receipts
      2. payments
      3. denials
      4. underpayments
      5. pre-certification parameters
      6. identification of the best candidates for post-payment audits
   4. The Audit
      1. They’ve paid you, and now they want all the money back (plus penalties and interest, of course).
      2. They send letters to your patients and even visit their homes in some cases.
      3. Your legal defense costs climb.
      4. You face losing your license with your state board.
      5. You’re completely distracted from practicing.
      6. The mental stress weighs on you and your loved ones.
      7. What do they get out of it? It’s a simple calculation—a 13:1 return on investment. Between the payments they take back, the penalties, and the interest, they get $13 back for every $1 they invest in a post-payment audit. What a racket!