Going Cash
Hey, everyone. Dr. Brian Capra from Genesis Chiropractic Software once again. Tonight I am going to talk to you about going cash facts, myths, pretty straightforward, pretty simple, very misunderstood out there in the profession. I understand how we wound up in this situation. Tired of dealing with insurance companies, tired of submitting claims and following up on claims and dealing with having to resubmit claims and submit documentation and all the rigmarole. I understand it 100% why you’d want to quote unquote go cash. Quick quote from Ayn Rand. If you don’t know Atlas Shrugs, read the book, watch the … There’s movies now you can watch. So watch the movie. It’s really cool. “Contradictions do not exist. Whenever you think you are facing contradiction, check your premise. You will find that one of them is wrong.” So I’ve talked to a lot of doctors that thought going cash would kind of keep them safe and make it simple, and they wouldn’t have to document as much. They wouldn’t have to use the coding as much and all that stuff. But now we know that’s just not the truth anymore. State boards are requiring Medicare-level documentation and coding even for cash patients. So it’s not even the insurance companies anymore. This has become a standard of care. You’ve probably heard that kind of terminology before. Standard of care means it’s just required because you’re a doctor and it’s expected of you. So what does that mean? So let’s talk about going cash. Obviously insurance companies ideally never have to pay you, right? So we think by going cash and submitting superbills to pay or giving superbills to patients that we’re kind of playing along with the game. That’s not the game. That’s not what they’re looking to do. They’re going to have to pay the patient anyway, so that’s really not the problem. So there’s really no such thing today, and don’t shoot the messenger, as a cash practice anymore. There was a long time where you can kind of get away with that, but it’s just not the truth anymore. Number one, you have to submit claims to Medicare for Medicare patients. That’s the law. So right off the bat, I know a lot of the cash doctors say you’re cash, and I know you know that you have to submit to Medicare. So you just submit to Medicare and that’s it and everybody else gets a superbill. I understand that scenario there, but again, state boards now require Medicare … So number one reason that cash doesn’t really exist, you have to submit claims to Medicare. Number two, state boards now require Medicare-level documentation and coding even on cash patients. So you have to do it anyway. The only difference is whether or not you have to submit claims, follow up on claims, and so on. The third and probably biggest reason that there is no such thing as a cash practice is even if you give superbills to patients today, insurance companies can still come back and audit your documentation for those claims to support that it was actually done. So what they’re going to do is tell the patient this is denied, ask your doctor for documentation. If you don’t provide that documentation, you’re in trouble. If you do provide that documentation and it doesn’t support that, you could also be in trouble because what are they going to do? They’re going to report you to your state board, which in my opinion is an even bigger problem than an audit. You get audited, worst case, you have to pay a bunch of money back. Obviously there’s legal fees involved. That’s never … it’s not fun. There’s a big distraction. It’s a nightmare. But I would say a bigger problem is actually getting reported to your state board. Why? Because now it’s your license and your livelihood. So the insurance companies have figured out every single possible scenario to tighten the screws. You know, there’s the old Godfather quote, “Just when you thought you were out, they pull you back in.” That’s because there’s really no such thing as a cash practice. Now a little light at the end of the tunnel. The wrong question, what we should not be asking ourselves … I know how we, as this profession and how we think, we just want to save people, we just want to save their lives, we’re just trying to serve people. We just want to adjust. I get it. I’ve been in the same, you know, your shoes. I was the same way, except today the game is just a little bit different. Even if you want to see cash patients, and we work with CHUSA and other companies that do cash discounts, legally doing cash discounts. That’s great. When they are in the cash portion of their care plan. When they’re not and it’s medically necessary, insurance is still in the game. So that means the state board and/or the insurance company is in play. All right, so the wrong question is how do we see patients to avoid documenting and coding requirements? Can’t do it anyway. So that’s the wrong question. The wrong premise, right? Ayn Rand. You’ve got to check your premise. It’s just wrong. You can’t do it. The fact is we can’t do it, so state boards are now requiring it all. The correct question, what we should be asking, how can I see patients regardless of their payer, whether it’s insurance, because at some point in their care, they’re either insurance, they’re allowed to get covered by insurance or they should be covered by insurance or they should not, right? Meaning that they’re not in acute care or not in active care. So how can we see patients regardless of the payer and have systems in place that make it feel like, for the doctor, for you, for your team, like a cash practice as
How insurance companies use your money to audit other chiropractors
Hey Ron, Dr Brian Capra here from Genesis Chiropractic Software. We have gone over the past couple of days a couple of high level things about insurance companies and your collections and your revenues. Number one, insurance companies make their money by collecting interest on the money that they should have already paid you, and they should have already paid you the day you saw the patient, so there’s no reason why we should be waiting weeks for check from insurance companies. Number two, we learned that the whole system is actually rig to allow them to create this environment where they can not pay or not even respond to you for 30 days. There is no reason why they should be allowed to do that. In order to do that, they had to actually collude against physicians and that there was a law made to actually make them exempt from antitrust law, allowing them to actually rig this whole system and make all these crazy rules. Now we’re gonna talk about some of the tactics, the actual real life examples of what they are actually doing. Now that we know how they make their money and that they’ve actually ranked this whole system, you’ll start to see that all this is really nonsense. Remember, they should pay you the minute you’re finished adjusting a patient. There’s nothing preventing them technically from doing that. Let’s make sure we’re keeping that in mind as we go through these things. I’m going to go over just some high level tactics that they use. Just generalities first. Then we’ll go a little bit deeper in. Number one, they make it difficult for you to get the claim to them. We’ll talk more about that. They make it difficult for you to prove that the claim was necessary. They pay very slowly, or they actually just respond to you very slowly. Every time you send a claim or resubmitted claim, it’s a slow response time. They pay you less than they should. That’s very sneaky. I’m going to get back into that a little bit later. And then after they’ve paid you and the patient’s already out of the picture, they’re going to take your money back. I’m going to keep on going through here, a couple more things. Another thing that they love to do, and this is, again kind of, if you ask me, very sneaky, very subtle. They put themselves between you and the patient. If you think about it, the doctor has to make the claim properly, right? You have to submit the claim, and I say doctor, your office, whoever, you have to prove that it was necessary. It’s your fault if it takes too long for the payment to come for their care. It’s your fault if you charge too much or more than is the allowable amount in that area. And it’s your fault if this claim comes back later on and it wasn’t necessary and they accuse, and you have to go through an audit and accuse you of fraud, that was all your fault. And so you think about patients getting EOBs and calling their insurance company, and they’re being told, “Oh yeah, the doctor hasn’t submitted. Oh yeah, they didn’t prove necessity. We’re waiting for documentation.” It’s been taking too long. Were they charged? Why is there a balance? The patient’s asking the insurance company. They’re just saying, “Oh yeah, they charge more than we allow.” The first call, we’re lucky if they call our office for balances. Right? We’ve got to keep these things in mind as we go along here. Let’s dive a little bit deeper. What are they allowed to do? They have 30 days to pay. Ridiculous right off the bat. There’s no reason why that should happen. They should pay you right away. Nothing preventing, nothing preventing them from doing that. Each patient’s coverage is different. We have tons of different plans and groups and all this stuff. Why is that? Why is it so complex? It’s not because it’s better for patients. It’s because it’s better for their interest gained on your money. They’re just trying to drag out this payment cycle as long as they can. Complex coding. Right? I have a list here. Diagnosis codes. You know the ICD-10 came out. That made it a hundred times more complicated, literally. The order of your diagnosis codes, in some places in some carriers, actually matters. Which diagnosis code you put first. The CPT code, obviously, with different levels, right, so you’re 989 codes and your exam codes all have different levels built in for you to be able to tell them which level of service you did. Does it really matter that much? The modifiers that go along with this, the diagnosis code linking, the units. We have time codes. We have one on one codes versus group codes. It’s really, it really doesn’t have to be that complicated. It’s there and they always love to tell us, “Oh, it’s so that we can track the, the patient’s progress ,and we want to make sure that it’s based on the quality of the care that the doctor’s giving and then we’re actually paying for the right care.” Then you got the HCA form, which has 9 million fields on it, all of which have to be filled out perfectly in order for that claim to be accepted on the other side. Obviously technology is helping that out. Then you have the EOBs. Every insurance company has, when you get denials, there’s denial codes and that’s their explanation. Every insurance company has a different code and different explanation that you’re supposed to know. And so again, it makes it very complicated for you to just to figure out why things were denied. Probably one of the most sneaky things that they do, and this happens a lot and in Genesis we see this a lot. We
The #1 way insurance companies make their profit
I want to talk to you today about what insurance companies really don’t want you to know. And then I have a checklist. We’re going to go down 10 things. I’m just going to cover one today. And I think, when you understand this one thing, you’ll probably get, and understand, that there’s a lot more to it than you realize. So, what insurance companies don’t want you to know. When I first started chiropractic, first of all, I own Genesis, a software company and chiropractic billing service. Scheduling, documentation, billing. We’re a billing service, I own a billing company. When I started chiropractic and chiropractic practice I had no idea about anything about billing, coding, documentation. Audits were just starting to happen. But I quickly realized what a big need that was. So I started to dig in and I actually went out and found some people outside of the chiropractic profession, in the finance world, in the technology world, in the artificial intelligence world, that’s how I wound up with Genesis as a company. But what I started to realize is that insurance companies are just like every other company. They’re made up of people, process, and technology. They want to turn a profit. But what I did not realize is how they actually make their money. I used to think that it was just simple. They collect a bunch of premiums from patients and they don’t pay insurance claims. That’s of course one way, but there’s actually much more to that. When we’re talking about how they make profit, over 50% of insurance company’s profits are made on what is known in the financial world as the float. Float is interest. Float is interest on money that is not yours. In this case, your money, the chiropractor’s money. So the insurance company is making interest on your money and it’s not their money. When is is not their money? It’s really interesting because in the real world, on Wall Street for example … again, my partners today, in Genesis, are from the financial world, from Wall Street in technology. On Wall Street, every time a transaction happens on Wall Street, by the end of the day everybody has to get paid. All the parties involved in any transaction and on Wall Street, a transaction can be infinitely more complicated than an insurance claim. Diagnoses codes, procedure codes, all that good stuff seems complicated to us, but on Wall Street they’re way more complicated and by law everybody has to be paid by the end of the day and the technology exists to make that happen. So you understand the technology exists today for you to be paid the moment or the moment after you’re finished adjusting the patient. All right so, when you start to realize that insurance companies are actually making more than half of their profit on the interest that should be on your money. The interest on your money. Meaning, after you see the patient, that next moment the money is technically yours. Everything after that is bologna. We’re going to start talking about all this stuff in a little bit more detail and how they actually … First of all, think about these things. How do insurance companies get to rig the system so that they have thirty days, for example, to pay your insurance claim? Why are there diagnosis and procedure codes? Why are there modifiers? Diagnosis code linking? Why is there the ability to deny your claim, medical necessity, documentation? Why does all that stuff exist? So, what I’m going to start to talk to you about over the next few days is all the little details that we take for granted as we think is normal, or they should be there, or it’s for the patient’s benefit, or medical necessities all about the patient, or about the performance of the doctor, or about the results that you get is really a bunch of nonsense actually. Actually the moment that you adjust that patient that money is yours. Insurance companies make more than half their profit on interest on your money. So I’m going to talk to you about, again, over the next few days, the top ways they’ve actually been able to rig the system, put this in place. Then eventually, maybe I’ll get into a little bit more about Genesis and how we’ve actually … helping doctors leverage technology, and automation, artificial intelligence, and processes, and people to actually beat them at their own game. We’re the only company that’s been able to do that with artificial intelligence patented. Not to talk about Genesis, I just want to help you understand how insurance companies, what they’re really up to. It’s a business and it’s their right to run it and the rules are what they are so if we want to change them, we either got to change the rules or we got to learn to learn how to play by the rules and beat them at their own game. Hope for this was a little bit helpful. Again, insurance companies are making more than half their profit on interest on your money sitting in their bank accounts.
What to Look For in a Billing Company – Chapter 11
Chapter 11 What to Look For in a Billing Company As we have seen, Genesis has automated everything with the exception of following up on claims that need a phone call. So the word billing in billing company really does not apply anymore. We are really a follow-up company. For clients who keep things in-house and use Genesis, they really do not have a billing department anymore. They have a follow-up department. What You Do Not Want Sometimes it is easier to think about what you do not want rather than what you do want. We’ve already covered what you do want and why. Here is what you do not want in a billing company: No automation, just lots of experience You do not want a company that does not have automation and just says they have lots of experience or are really great billers. Genesis has been in the business for 14 years and processes millions of claims for practices all over the country. We have many expert certified coders (hundreds, actually) with lots of experience on our team. You might be saying, So what? One biller does not know more than what insurance companies have built into their AI. What happens tomorrow when the insurance company changes tactics? Are billers looking at data across thousands of practices and millions of claims? Are they building new automation and AI to fight back against insurance companies’ tactics? Can one very experienced person follow up on millions of claims? No accountability I used to outsource to a company that would send me lots of reports every month. Guess what? I never had time to look at them. If you cannot see top-down reporting of their work in real time, forget it. How many claims need follow-up today? What is your AR > 120 days? Then drill down into reports from there if you want to or need to. That’s what Genesis offers. Billing companies love to talk about their reports and how they log into your system. No good. No control, no transparency, no accountability. You will wind up not trusting them. They don’t outsource follow-up I know what you’re thinking. I don’t want to speak to someone in India. Of course not. We would never ask a client to do that. With Genesis, you always speak to a resource in the United States. But we do want the insurance company to speak to someone in India (or another country). Why? Because they are doing the same thing. Remember how we said they have unlimited manpower? If we are going to beat them at their own game, we must do the same. Outsourcing your claims follow-up while still giving you transparency is one of our secret weapons. We have hundreds of follow-up resources in other countries driving insurance companies crazy every day. They are managed by resources here in the United States. They are only paid when you get paid. They use another software If they are using another software, then no thank you. I shouldn’t have to explain all the reasons that this is a deal breaker. Your practice management end must be tied to your billing and follow-up if you want real control, transparency, accountability, and a chance to beat insurance companies at their own game. Even if you are using another cloud-based system, it is not enough. That would mean the biller is using the same exact system. But what about Single Point Management? Yes, control and transparency. Low fees and what they mean A billing service should be charging only a percentage of what you collect from the insurance company—not on copays and deductibles. You want them to have all their incentive focused on getting the money you deserve from insurance companies. The average fee for this in chiropractic is between 6% and 10%. The number varies based on what your average collection per claim is. Anything lower is a big red flag. It means they are probably not going to follow up on every single claim and that they will just take the easy money. Since most of them have junk technology, you’ll never really know. The low fee also tells you they are not investing in technology and are most likely using the system you already have and logging in remotely or using some other system. See #4 above. That’s a deal breaker. Some billing services advertise a very low percentage, but then you find out it is a percentage of what you charge. Some of our clients actually want this for some reason, and we do it. However, you’d better make sure you have a way to see everything they have done on any claim and have a way to know they are following up on every single claim that needs it. Some charge a lower percentage but take a percentage of everything you collect, including cash, copays, and deductibles. Watch out for that one. Another pitfall of low fees is that no system (except Genesis) can track underpayments. So while they give you a low percentage, you never really see the income from your underpayments. They just do not have the technology or enough workers to go after that money for you. It could cost you tens of thousands of dollars per year. If you do not keep insurance companies accountable, they will continue to take advantage, and it will only get worse.
