Leveling the Playing Field – Chapter 6
Chapter 6 Leveling the Playing Field Vultron When I was a kid, there was a Marvel comic book called Vultron. There were basically five superheroes who drove around in their own individual robotic lions. When they came up against a really formidable opponent, they were able to join all their lions together and form one gigantic warrior-shaped robot. Of course, working together, they were able to defeat the enemy that would have otherwise destroyed them individually. Today, my son watches Power Rangers. It’s basically the same concept. Judo Judo is a very well-known martial art. The main idea is to use your opponent’s aggression or momentum against them. So when the opponent swings at you, for example, you move out of the way at the same time you push them or throw them in the direction in which their momentum was already taking them. Ultron-Judo Take these two concepts and smush them together. That’s how we beat them at their own game. We use their momentum and their own tactics, band together using a more powerful technology than we have individually, and destroy our formidable foe. As we’ve been learning about insurance company strategies and tactics, I told you about the three components of any business: People Process Technology We also discussed one very specific process they have: the audit. We have dived into each component and seen how insurance companies are really just leveraging people, process, and technology from a totally different perspective or paradigm than we are. People Insurance companies have unlimited cheap labor. Their highly paid staff only works on things that have a huge return on investment—audits, for example. We have been doing the opposite. We’ve been paying our highest paid employees to call insurance companies, verify benefits, enter charges, enter EOBs, and dig into reports looking for claims to follow up on. That’s gotta stop…if we wanna win. Process All these things—missed visits, new patient checklists, re-signs, inventory management, credit card charges, documentation, coding, EOB posting, charge entries, claim submission, failed claim identification, secondary submission, patient statements, cash patient statements—they all matter. And they are not going to go away. But we can certainly be more efficient and effective by using AI and automation. Asking your awesome biller to do a good job with inferior technology is like sending them into a nuclear war with a stick. Technology Technology—that’s a big one. Remember, insurance companies leverage huge databases, automation, and AI, forcing your people to follow every manual process at a huge cost to you, both in terms of money and liability. Buying technology that addresses only one component of your practice while not addressing the big picture is a mistake. Until 2004, there was no way to beat insurance companies at their game or even compete. No small practice could afford enterprise-level technology that could compete. Now there is a way. The Internet changed everything. Here is the new solution—Genesis. In 2004, we started a company built in the cloud. This was before the cloud was a thing to most doctors. If we are going to win, we need a paradigm shift in how we think about our businesses and how we play the game. It was a new approach, leveraging people, process, and technology to beat insurance companies at their own game, optimizing revenue, retention, and compliance in far less time, regardless of your cash/insurance payer mix. It is a new system and paradigm. It is smart, and it learns. It allows doctors to band together with one technology and use the insurance companies’ tactics against them.– Ultron and Judo, if you please. It has a life of its own. I named it GENESIS. Advantages With all of our clients submitting claims through one database, we could analyze data across all insurance companies all over the country—the same way insurance companies analyze us. The cloud provided more HIPAA compliance for patient data than traditional systems like ChiroTouch or Platinum (more on this later). We could now leverage AI and automation, just like the big boys, and alert doctors in real time about coding and compliance risks. Real-time transparency was achieved. Now a doctor could see exactly how many claims needed follow-up and in real-time accounts receivable numbers from anywhere there was an Internet connection. No more digging through reports, unless you have time for that sort of thing. Providers with more than one practice, or multi-specialty offices, could link them in the cloud and aggregate their own performance metrics. It was not just for insurance. We could also leverage automation to improve patient retention and staff efficiency, even for cash patients. Better technology development—on the fly—old systems are written in hieroglyphics. Cloud-based systems have the distinct advantage of being able to change the language as new ones are developed. It’s like building and refitting an airplane while it’s in the air. Billing Network: The Network Effect For the first time in the history of the profession, there was a billing network that any provider could join. When they joined, they were working with thousands of other users all over the country and contributing their data to the cause. (NOTE: In case you are wondering, no doctor could see another doctor’s data. Doctors maintain ownership of their own data.). It is a legal way to band together and fight back! Artificial Intelligence With patented technology, we now could leverage AI. It is the first step and goes hand-in-hand with automation. AI helps find exceptions. These are critical items that affect your patient retention, your cash or insurance collections, and your compliance. Here are some examples of exceptions—things AI can identify with zero work for you or your staff. Practice-specific A claim that is in the process of being created but is missing modifiers, linking, proper diagnosis codes, correct procedure codes A claim that is not supported by the daily note A visit that has not been billed out (even if it’s cash) or is missing a signed note A patient that does not
Kicking You While You’re Down – Chapter 4
Chapter 4 Kicking You While You’re Down Recap We know how and why insurance companies rig the system and make all the rules. 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: People – much cheaper people Processes Technology The Audit [/vc_column_text][vc_column_text css=”.vc_custom_1520833800265{margin-bottom: 0px !important;}”] 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. 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. You are one person; they have unlimited people. 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 Benefit verifications Pre-certifications Hunting and pecking for codes, modifiers, linking, ordering, units, and so on Documenting every visit, hoping you’re getting it right Submitting the claim to a clearing house (God forbid that you would send them by paper) Correcting claims in the clearing house before they get sent Posting EOB Finding unpaid claims, underpayments, and denials in aging reports Submitting to secondary payers Calling insurance companies for denials, underpayments, benefit verifications, pre-certifications Submitting supporting medical necessity documentation and appeals Resubmitting claims Collecting patient balances Their manual steps Answer the phone when you call on a claim, benefit verification, or pre-certification Auditing you Technology and Automation—How Can You Compete? What technology are insurance companies investing in? They build a massive database in the cloud, collecting data across all chiropractors and other physicians. Their AI looks for trends and finds outliers for coding documentation follow-up The AI then automates the rest based on what it is learning. They automate: claim receipts payments denials underpayments pre-certification parameters identification of the best candidates for post-payment audits The Audit They’ve paid you, and now they want all the money back (plus penalties and interest, of course). They send letters to your patients and even visit their homes in some cases. Your legal defense costs climb. You face losing your license with your state board. You’re completely distracted from practicing. The mental stress weighs on you and your loved ones. 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!
Their Tactics and Their Rules – Chapter 3
Chapter 3 Their Tactics and Their Rules Recap The patient is the insurance company’s customer, not yours. The system is rigged in the insurance company’s favor by design. They make the rules. They are legally protected by the federal government. They make money on interest. So how do insurance companies pay claims, make a lot of money (from interest), and still look good in the eyes of their customers? 5 Generic Tactics They Use Make it difficult for you to get the claim to them in real time. Make it difficult to prove necessity and deny claims, especially in real time. Pay very slowly. Pay less than they should. Take the money back much later after their customer is satisfied and out of the picture. Making Patients Hate You Instead of Them Think about this from the patient’s perspective. They have no idea about the things we’ve already discussed. They just want to get their visits paid for because they paid their insurance premiums. Of the five items above, which one makes insurance companies look bad in the patient’s eyes? None of them! It is the doctor who has to make the claim properly. It is the doctor who must show why this care was necessary. It is the doctor’s fault it is taking so long for the insurance company to pay for your visit (see tactics 1 and 2). It is the doctor who charged you more than is reasonable for your area. It is the doctor who billed you fraudulently. Now we have to investigate. They make the rules, right? What are the rules that help them save face with the patient while they hold on to your money? The Rules Insurance companies have 30 days to process a claim instead of paying in real time. Each patient’s coverage is different. They have a very complex coding system that determines what they pay you. The codes are actually not really necessary to pay. The complexity is really there to make it very difficult for you to submit the correct claim in real time, slowing down or preventing payment and increasing the interest they collect. With only the list below and its possible combinations, the chance of making a mistake is in the hundreds of thousands. Diagnosis codes, ICD-10 (ICD-11 is coming, believe it or not) Diagnosis code ordering CPT codes Modifies Diagnosis code linking Number of units Timed codes One-on-one Vs group Levels of codes. Exams and re-exams, for example HCFA – The complexity increases more with the submission form/bill/HCFA. It needs to be sent with a lot of information. Anything that is incorrect is grounds for denial and/or delay. Remittance Advice – The EOB Taking an EOB (Explanation of Benefits) and posting the line items takes a highly skilled employee, but they leveraged technology to send the EOB to you. We’ll cover more on the economies of scale, the workforce, and technology a little later. Every payer has his or her own denial codes and format, which significantly slows down your posting. Underpayments – Finding an underpayment means your staff needs to remember every CPT allowable or contracted amount for every payer. When something is underpaid, it is almost impossible to find. It looks like it was paid after all. Over the course of your career, this could cost you tens of thousands of dollars. Very sneaky, if you ask me. Documentation Ambiguous requirements – Subjective, objective, ADL, assessment, plan. Functional improvements, outcome assessment tools. Blah, blah, blah. Thirty compliance “experts,” 30 different opinions. Matching documentation to the coding adds yet another level of complexity. Most technology does not help you get this right—your documentation matching your codes for each visit. Lots of systems say they have fast notes, but what about the coding complexity? Does it warn you when you’ve made a mistake? Are they really looking at insurance companies’ trends and improving this over time? Are they reviewing real-life claims data and updating the system to make sure your claims are accurate? More on this later when we get into beating them at their own game! It is all nonsense really. They know it. Now you know it.
How They Rig the System – Chapter 2
Chapter 2 How They Rig the System We are getting to the root of the issue, but there’s a little more to the story. When I started Genesis Chiropractic Software, I partnered with people from the Wall Street financial technology world. One of my partners is the former CIO (chief information officer) of the top bank in the world. Another is a Princeton University grad with a computer science degree and extensive experience, specifically in building AI technology for hedge fund transactions. Why is that important? It turns out that insurance claim transactions between the doctor and the insurance company are rather simple. When my partners first looked at the process, their first reaction was this: “Oh, we can just get them to pay these claims in real time. The transactions on Wall Street are way more complex, and they involve many people at the same time. The only difference is that everyone involved gets paid by the end of the day. It’s the law!” Did you hear that? It’s the law! Here’s where it starts to get interesting. Far more complex transactions happen every day on Wall Street, right? So why wouldn’t insurance companies do the same? And the technology already exists to make that happen. Why isn’t there a law that says doctors get paid for a visit by the end of the day? That’s a great question. I’m glad you asked. But remember, I already said they make money on interest, right? And you know there is no good reason you don’t get paid at the end of the day. I’m sure you’re probably starting to see what’s going on here. Insurance companies start collecting interest as soon as you’ve seen the patient. But that doesn’t answer this question: Why isn’t there a law that makes them pay you by the end of the day? Collusion and Consolidation We have all heard a lot in the news about collusion when it comes to politics. Well, here is real collusion that is well known and even legal. Seventy percent of US citizens are covered by just three insurance companies. Why? The big companies have gobbled up the little ones. But why? Not to be more profitable, but to be more powerful! Gaining legal power by consolidation Oligopoly – An oligopoly is not a monopoly. It is an economic structure in which just a few companies affect but don’t technically control an industry. And they don’t prevent each other from having a major influence on the market. A monopoly is when one company has total control of an industry or product. An oligopoly has many of the same benefits as a monopoly, but the most important benefit is that an oligopoly is more legal, and a monopoly is illegal. Insurance companies make the rules – Since the insurance industry is an oligopoly, just a few insurance companies have all the money, they have all the lobbying power, and they make the laws and rules by default. Did you notice that I said more legal above? I’m glad you caught that. What laws are in place to prevent this? That is another great question. Antitrust exemption: This is amazing—don’t skip it! Rigging a marketplace by working together—as an oligopoly—could still be considered a violation of antitrust laws. These laws prevent companies from having exclusive control and thus price fixing. You might remember the huge antitrust case against Microsoft—United States v. Microsoft. In a capitalist economy, monopolizing is taken very seriously. Let’s say every chiropractor got together and said we would no longer accept less than $45—or maybe even $1,000—from insurance companies for an adjustment. Insurance companies would report it to the federal government. Those chiropractors would immediately be shut down. The insurance companies would be correct, because doctors cannot collude against insurance companies. Antitrust laws are important because they protect consumers. The law applies to every industry, right? Nope! It turns out that there are a few exceptions. Guess which industry is one of those exceptions. You got it—the insurance industry. They are legally allowed to collude against all physicians, not just chiropractors. And they’ve used their massive resources to successfully lobby for laws that protect them even further. Even if we could prove they were rigging the system, we have zero recourse! If you want more information on this, read about the McCarran-Ferguson Act of 1945, a federal law that exempts insurance companies from most federal regulations, including some antitrust laws. So there is your answer. Why aren’t there laws that make insurance companies pay at the time of service? Because they have all the power, and their power is actually enabled and protected by the US government. They get to make all the rules!
