It’s that time of year again when I’m going through my email inbox and realizing there are more questions than I can humanly answer.  First, thanks for your emails. Even if I can’t answer them all personally, they do provide the bulk of the material for my blog posts.  After all, if 127 different docs all write in with a question on…XYZ…then I know it’s a point of confusion and one that needs some clarification.

Today’s topic:  Medicare ABN Over-use.

Somehow, somewhere down the line, chiropractors got the Medicare ABN confused.

And in our quest to be compliant, we hit our patients with ABN’s frequently.  Perhaps a little too frequently. And it can cause patients to panic, to get irritated or perhaps leave your office altogether.

Here’s a few facts to help clarify the muddy waters:

• The ABN should not be used every visit for chiropractic adjustments.  I have taken training calls with every Medicare carrier in the country and have heard this exact verbiage come out of all of their mouths.  If you’re using the ABN every visit, you’re probably doing something wrong.  Most commonly the error is made by the well-intentioned chiropractor who wants to cover their tail by issuing an ABN “just in case.”  Sorry to be the bearer of bad news, but the ABN is not designed for that purpose.  Medicare wants it black or white.  In terms of the adjustment, either (a) you believe the service should be covered (Active Treatment) and therefore you don’t need an ABN or (b) you deem that the adjustment is for Maintenance and therefore is not going to be covered.  Situation (b) requires an ABN.

• The ABN is not a blanket that covers any and all situations. Unfortunately, what most chiropractors want is a blanket form that will cover how Medicare will respond.  In other words, if they deny the service, you want to be covered.  If they pay, you’re good.  There’s no form for that. On the contrary, the ABN is designed for you to inform your patient that you anticipate the service to be paid (based on the fact that you think it is medically necessary, active treatment) or that you expect that the adjustment will not be covered because it is for the purposes of maintenance. So, the burden and the purpose of the ABN is for YOU to decide – not for you to try and guess how Medicare will respond in the grey areas.  As such, your ABN delivery should be more black and white.  And if you keep it that simple, you will probably avoid the headaches in the process.

• The ABN is voluntary for all statutorily non-covered services.  First let’s define statutorily non-covered services.  These are services that Medicare never covers in any circumstances.  Fortunately, this is simple: everything but your chiropractic spinal adjustment codes (98940,98941, 98942).  So anything else: exams, x-rays, modalities, massage and yes, even your extremity adjustment (98943) are services that Medicare never covers.  In these situations, issuing an ABN to inform your patient that Medicare won’t cover them is voluntary – yes, as in, not required.

Notice I am not saying not to use the ABN in these cases.  I am saying that it’s up to you – voluntary.  So, for some chiropractors who have panicked their patients by hitting them with excessive ABN’s – this may be a good choice.

I hope that clears up some of the misinformation out there.  Certainly, some more questions may arise if you’ve been doing this incorrectly – but that’s another post for another day…

Chiropractic Compliance: Medicare ABN Questions

Thanks to some recent Medicare changes, you can now anticipate the wonderful side-effect of other payers reducing your reimbursement rates for “multiple procedures”  — i.e. performing multiple services or billing for multiple units of a service in one day. While many payers have already implemented policies on “multiple procedure payment reductions,” the amount of the discount is going to increase from an average of 20% to close to a gargantuan 50% payment reduction!

How This Will Effect Chiropractors and Related Services

There are two basic ways that these reduction policies will affect our reimbursements:

Bad News Example 1:

• You provide a multiple therapy services in one visit – electric stim, traction, ultrasound, etc.

• Therapy # 1 is paid at 100% of contracted rate (still a discount from your billed)

• Therapy #2+ will be paid at 50% of contracted (an increase from the previous bad news reductions of 20%)

Bad News Example 2:

• You provide multiple units of a single therapy (Ex: Massage, Therapeutic Exercises, Manual Therapy, etc).

• Unit 1 of the therapy will be paid at 100% of contracted rate (still a discount from your billed)

• Units 2-4 will be paid at 50% of contracted rate (an increase from the previous 20% discount)

Like Numbers? Take a Look

When you do the math, you can quickly see how this makes our already ugly reimbursements even uglier…

Let’s say you or your therapist performs a 1 hour massage (4 units) billed at $100.  Your payers contracted rate is $15 per unit, so in the good old days you formerly would receive $60 for that service (a discount of 40% from your billed amount).

With the new multiple procedure payment reductions, you will now receive $15 for that first unit + $7.50 per unit afterward for a a new total of $47.50 (now your discount is $52.50 from your billed charges) – ouch!

In full disclosure, this may be an oversimplification because each procedure has different components built into the relative value unit (RVU) of the allowable amount for that service. For example, many procedures have a practice expense, a work expense and a malpractice component.  Add these three components up and the payer calculates the value for that service.  So, some slightly good news, the anticipated reductions are only supposed to effect the practice expense, not the work or malpractice expense.  So, all told the 50% discount will be slightly less than 50% but it will definitely be more than you want and more than the former multiple procedure discount which was in the  20% ballpark.

Why Are Payers Discounting My Already Discounted Fees?

Good question.  Effective April 1, 2013, Medicare increased the reduction rate of duplicated practice expense components from 20 to 50 percent as part of the American Taxpayer Relief Act of 2012.

However, these discounts are being applied by commercial payers as well.  For example, UnitedHealthCare’s May 2013 newsletter featured this rationalization:

“To align with CMS reimbursement for these types of therapy services, UnitedHealthcare will implement the 50 percent reduction to the practice expense component of secondary and subsequent therapy procedures, effective third quarter 2013.”

This sounds logical except that UHC is not Medicare and is not subject to what was passed in the American Tax Payer Relief Act of 2012.  But this provides them with a convenient opportunity to lower their reimbursements.

And unfortunately, you should anticipate other payers to do the same.

Recommended Action Steps

1.  Make noise. Like our medical counterparts, chiropractors need to band together.  Our associations need to work to negotiate fee schedules and/or at least prevent us from being subject to these unilateral, “unannounced” fee cuts. (In UHC’s case, I guess they did announce this. In May, they said, we’re doing this to you starting the 3^rd Quarter, which is July. But that doesn’t give much notice for us to respond.)

2.  Support Your Associations:  The only true way to fight these battles is to join our national and/or state associations and support them with the necessary funds to wage war against this.

3.  Consider Your Fee Schedule:  Far too many chiropractors are laboring under a needlessly low fee schedule.  We accept a payer’s lousy fees because the alternative is often our own lousier cash fees.  Some of you have been charging $25 for an adjustment for decades.  (Please give me the GPS coordinates of your bubble where you live exempt from inflation.)  Others of you raise your cash adjustment fees but throw everything else in for free, thus lowering the overall value of the services you render.  (If you can do that because you have free staff, please also send me the name of the temp agency, head hunter or parole agent by which you obtain staff willing to work for free)

4.  Don’t Be Afraid of Cash:  Yes, I am known as a billing/coding “expert” but at this point in time, I think it’s a little unsafe and insecure to be operating a 100% insurance based practice.  We cannot recommend services which we deem will benefit our patients just because their insurance either doesn’t cover them or coverage is so lousy, we can’t make a dime off those services.  If the patient truly needs the care, then we should recommend it and provide opportunities for them to be able to pay for it.  Think your patients won’t go for it?  Think again.  Take a field trip to your local spa.  They are not doing $29 massages.  It’s more like $129 per hour.  And they are not taking insurance.  And if you did your business homework, you would know that the “medi-spa” concept is growing like a weed. So, mostly that leaves us with a cash problem that primarily exists between our two ears. (If you can’t even get massage patients in the door or are thinking about starting this, you should consider my Build a $300,000 Massage Practice in Your Chiropractic Clinic – if I may say so myself, it is a great resource for building or improving a profitable massage program.)

 5.  Prepare Staff for Multiple Therapy Payment Reductions.  Now that you’ve read this post and know this bad news is approaching, educate your staff.  They will undoubtedly notice from your EOB’s that there is a little reimbursement shenanigans going on.  But there’s no sense in wasting their time appealing claims that are the subject of a new policy. And if they don’t notice, maybe it’s time to outsource your chiropractic billing and liberate that staff member to find a job for which their skillset is a better fit.

Bad News for Chiropractors Who Provide Multiple Therapies or Bill Multiple Units

If you do PI work, you may want to forward this on to attorneys that you work with as it could prove helpful to future MVA cases.

A recent case in the New Jersey Supreme Court ruled that Expert witnesses who testify in medical liability lawsuits must be in the same specialty as the defendant physician. In Nicholas v. Mynster, the court agreed that physicians who do not practice in the same specialty should not testify as expert witnesses.

Big Potential Impact For Chiropractors

While chiropractors are rarely subject to medical liability lawsuits, the potential impact of this court case is the heart of the matter at question: the establishment of a standard of care.

As you know, standard of care (or an outside “expert” witnesses’ interpretation of what is the standard of care, what is “reasonable” treatment and what is “medically necessary”) is a major obstacle that we routinely face as chiropractors.  Whether it is an IME cutting off your care, a paper reviewer who decides that your treatment was unnecessary or an auditor demanding money back, standard of care it at stake in much of what we do.

So, back to the case and its potential to apply to what we do…

Who Decides the Standard of Care?

“Since the liability issue invariably is whether there has been a breach of the standard of care for the medical specialty of the defendant physician on trial, that information comes best from someone practicing in that same field,” the medical associations argued in the brief.

The plaintiff in the case, Edward Nicholas, was treated for carbon monoxide poisoning at a hospital emergency room in 2005. Christopher Mynster, MD, a board-certified emergency medicine physician, treated Nicholas with 100 percent face-mask oxygen and recommended his admission to the hospital. The plaintiff suffered a brain seizure, and he and his wife filed a liability lawsuit. To support their case, Nicholas supplied the testimony of a Utah physician certified in internal medicine, critical care medicine and pulmonary diseases regarding the appropriate standard of care. The witness testified that hyperbaric oxygen should have been supplied instead.

Although an expert in hyperbaric medicine, the witness was not board certified in either of the specialties of the defendants.  As such, the New Jersey state supreme court pointed to the state’s Patients First Act and ruled that lawsuits must abide by the law’s requirement that expert testimony must come from a physician in the same specialty as the defendant.

Here’s the Possible Impact For Chiropractors

Beyond medical or product liability, the obvious victory in this case is that a doctor should have the right to have someone in his own specialty review his case. It’s no secret that the vast majority of medical reviewers employed by payers (whether PI or commercial insurance or even Medicare) are NOT chiropractors.  Typically, they are nurses.  Occasionally, they are internists, GP’s or other physicans.

This recent case may change this fact and require that chiropractors review chiropractic claims.

Furthermore, many of us have faced “expert witnesses” in PI cases who were anything but experts in chiropractic.   Again, thank New Jersey for great potential is here to remove that. Some states already have an “every category of provider” or similar laws which puts chiropractors on equal footing with MD’s and other physicians. This court case also appears to support the notion.  A “higher ranking” physician should not simply rule over the little guys.  Instead it should be apples to apples.

Fight For Your Right to…

There was a silly song in the 80’s the proclaimed fighting for your right to…party.  Well, that may not be the noblest of goals nor is it one that most mature adults would stake their life on. But the Beastie Boys anthem aside, even if you’re not chummy with lawyers and have a jaded view of our political system to get anything helpful done, don’t miss out on the potential of the fine print here. The bottom line is that the good doctor in New Jersey FOUGHT BACK!  Of course, I’m sure the lawsuit was of sufficient magnitude to catch anyone’s attention but the reality is that few docs (of any specialty) actually fight the bad news coming their way.

The “official” term for such a defense is called an appeal.  And research shows that math is on your side – approximately 64% of all appeals win!  The sad news is that less than 10% of all physicians actually appeal.  They don’t fight for their right to get paid (and probably aren’t putting up much of a struggle to party either).

Don’t be one of them.  An insurance company wrongs you – fight back. A payer claims that you can’t do X Y and Z procedures all on the same date even though you added modifiers correctly – fight back! Someone denies your care – don’t accept their word as gospel, fight back.  Someone demands their money back for services you’ve already rendered in good faith – hold on to your wallet and fight back. And yes, even when the insurance misquotes your verifications – fight back!

Believe it or not, the law is on your side.  There are court cases and successful appeals waged in all of the above examples and more.  Don’t like writing letters or don’t know where to start?  Consider getting the new edition of our popular Chiropractic Appeals Toolkit – it’s all done for you!

Whatever route you choose, don’t forget to fight for your rights!

A Landmark Court Case For Chiropractors Fighting For Their Rights?

Hopefully, by now, you have heard about reporting requirements for the Medicare PQRS.  Yes they are mandatory and yes, you need to start reporting them this year in 2013 or you will face penalties starting in 2015.

Yes, that’s two years away but the reason time is running out is this:

1) In order to “successfully” report PQRS, you must report the measures on every visit where you have billed a 98940, 98941 or 98942.  In 2013, you must satisfactorily report on both measures at least 50% of the time and perform each measure at least once to qualify for the incentive bonus.

2) The elephant in the room is this:  if your report your PQRS “incorrectly” you may be rolling out the red carpet for a Medicare audit.

If you have no clue about the whole PQRS requirements, don’t know what G-codes I am referring to and obviously haven’t started reporting, here are some quick facts:

Quick Facts About Medicare G-Codes and PQRS Reporting for Chiropractors

• You don’t have to register or do anything special to begin reporting PQRS measures
• All chiropractors are required to report regardless of their status (Par vs Non-Par)
• The G-codes for the PQRS reporting are not the same as G-modifiers related to the ABN
• DC’s who successfully report in 2013 will be eligible for a 0.5% bonus payment in 2015
• DC’s who do not report PQRS will be penalized 1.5% starting in 2015 and their payments will continue to decrease by 2% in 2016.
• It’s really not that hard to report!

If You Haven’t Been Reporting G-Codes Yet…

You are not alone!  It seemed to me that at the end of last year and the beginning of 2013, all I heard was articles on G codes.  Quite frankly, I assumed everyone was as sick of hearing about this as I was.  After all, it’s two codes and overall, pretty simple stuff.

Fast forward to present date (May 2013) and after having conducted 8 live seminars since the beginning of 2013 on chiropractic billing, coding and documentation, I am forced to stand corrected.

From my informal surveys of seminar attendees, apparently everyone did not get the memo.

In fact, fewer than 10% of my seminar attendees appear to be reporting G codes thus far.   And of those who are, 98% were not confident they were doing it right.

And since we are nearing the halfway point of 2013, you have precious little time to earn a bonus this year for doing so.  Perhaps more importantly, if you place this on the backburner for too long, you will risk being penalized on your future Medicare reimbursements.

Action Steps Depending on Your Self-Assessment Category

Philosophically Opposed:  I have spoken to a number of DC’s who seem to be against this reporting requirement in principle.  They simply don’t want to give “the man” any more data and don’t trust what Medicare or any other entity is going to do with it.  Naturally, they don’t want to report.  If that’s you—fine.  Don’t report and be prepared for your penalty in a couple of years.

Mathematically Challenged:  There is another category of chiropractors who are wondering if the requirements are worth their effort.  Typically these docs see very few Medicare patients and don’t really expect a bonus or penalty to impact their wallet that much.  I can appreciate this position.  If you’ve only collected $2000 from Medicare in the last year, a penalty of 1.5% ($30) doesn’t seem like much to get you motivated to report.  For that matter, the 0.5% ($10) doesn’t exactly light a fire to make you want to report either.  If you are on the fence, do the math, make your choice and move on.

Uninformed Do It Yourselfers – If you were shocked by this post, blatantly unaware of the creeping deadline and sufficiently motivated to get ‘er done, then…well…get to work!  It’s likely you have a treasure trove of articles stuffed in your inbox, amongst journals and other resources all explaining the G-codes.  You just have to read the materials, put the insight to action and do it quickly.  (BTW, if you can’t find your resources, you might want to consider spending 15 minutes and taking our fast-paced, super-simplified OnDemand webinar on How Chiropractors Can Easily Report PQRS & Medicare G Codes (click link to purchase access and watch anytime)

Almost Everyone Else:  Whether you just haven’t gotten around to reporting the G codes, are confused about the PQRS requirements for chiropractors or are just now crawling out from under your rock to suddenly hear about this “new” mandatory Medicare measure, the fact remains the same:  you need to start reporting in 2013.  Take a big breath.  It’s not that difficult.  In fact, I’ve put together an easy to understand OnDemand webinar (watch anytime) that will have you up to speed in about the time it takes the average chiropractor to see a new patient.  If you don’t dig the webinar format, I’ve also included notes so you can get going quickly.  Don’t delay – June will be here before you know it.

Those Who Are Already Reporting the Medicare G codes  —  Congratulations!  You are (definitely) ahead of the pack and are (probably) on your way to earning a bonus.  One quick test to make sure you are doing things right:  you should be receiving a N365 code on your EOB’s or your electronic claim remittals.  This N365 code indicates that Medicare has successfully received your G code measures.  Reporting but no indication you are doing it right?  Go back up one category and follow the advice there – but give yourself an extra cookie for your efforts J

Tom

PS – Blatant Commercial J —  one unique “twist” about my PQRS webinar is the “audit angle” that I discuss.  I have yet to see anyone clearly mention exactly what Medicare is going to do with the PQRS reporting and discuss potential audit triggers or traps.  So, if that’s something you wish to learn, you may also be interested in investing approx. 30 mins of your time on the How Chiropractors Can Easily Report PQRS & Medicare G Codes webinar (click link to purchase access and watch anytime)

Time is Runnning Out for Mandatory Reporting of Medicare PQRS Codes

With auditors examining our every move, many chiropractors are growing increasingly concerned about the state of their documentation.  Here’s the really bad news: as a Certified Professional Auditor and Professional Coder myself, I have reviewed countless chiropractic records and many DCs have good reason to worry.

Here’s the good news: this article will teach you how to avoid surprisingly common and easily overlooked mistakes in your documentation that generally spell big trouble during an audit.

First, why the focus on the little items?  Here’s why. Most audit tools used by insurance companies have about 18 items that a chiropractor would need to pass, typically with an 80% score or better.  If you do the math, that means you have to get 15 items “correct” to pass your audit.  Unfortunately, that doesn’t leave much room for error. So you simply can’t afford to make mistakes, especially those that are small and easily preventable.  With that in mind, here are the most common “small” errors that I see chiropractors routinely make:

• SLOP (instead of SOAP) — Most chiropractors were trained to document SOAP notes.  You know the drill.  S = Subjective, O=Objective, A=Assessment, P=Plan.  Plain and simple, those are the basic requirements for your notes.  Miss a letter and really all you have is slop that won’t justify your care.  Yet, far too many chiropractors do that.  They skip the S or the O or the A or the P.  Sure, we understand your busy.  But there are some corners you just can’t cut. And this is one of them.

• Signatures – There are a variety of “acceptable” signatures that Medicare and other payers will permit as standard documentation, but the one signature that is definitely not acceptable is the one that is absent.  Put simply, you are required to sign all daily notes in some way, shape or form (See Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section 3.4.1.1 B).  If you are utilizing EMR, you are likely ahead of the game, as this is generated with the push of a button.  If you have delayed using EMR, perhaps the cramp in your hand you get from signing every note will persuade you!

• Abbreviations – If you are audited, don’t count on a chiropractor reviewing your records who will know what “PR-L” or “ASRA” or even “Sublux” means.  For that matter, even a non-chiropractor may have difficulty with non-specific abbreviations like “PT.”  Did you send the patient for Physical Therapy or part-time work?  The auditor is not going to try and translate your abbreviations, especially if a key isn’t present that explains them.  A wonderful SOAP note with one unidentifiable abbreviation can cause you to fail your audit. So, make sure that you are spelling it out clearly (another advantage to EMR, push the button and the word comes out!) or that you provide a key that clearly translates all your abbreviations.

• Referrals – As the saying goes, if it isn’t documented, it didn’t happen.  Sure you may have referred your patient to receive massage therapy, but where is it in the SOAP note?  If you are trying to get that massage visit paid, you better be able to track a referral somewhere.  Insurance company denying the necessity of your care? Where is your documentation regarding your patient’s visit to the Orthopedic Surgeon whose recommendation was to continue with chiropractic care?  You should be documenting all referrals to and from your clinic.  An auditor who looks through your notes and finds none does not conclude that you never refer. He thinks that he has found a chiropractor who fails to document thoroughly and looks to see what other mistakes he can find.

• Legibility – This should be no issue for those using an EMR system, but for the docs who are still considering the switch, let me say this: Cranky auditors have no reason to try and decipher your chicken scratch! They can just declare your notes illegible and move on.  Remember, these people are paid on volume, so they want to give you the pass or fail and move on quickly to the next victim.

• Identical Notes – If every one of your visits looks the same, watch out!  Certainly EMR can make note-taking simple and easy, but this is one area where there can be too much of a good thing.  Do not simply copy one daily note to the next visit after visit without ever making a change.  After a handful of visits or so, it is apparent that you have a nice system that you are not using correctly!

• Phone Documentation – Does your staff ever speak to a patient who cancels for some other medical reason?  Do you speak to patients over the phone about care issues? If either of these situations are happening, they better be documented!  As above with referrals, the lack of this information actually speaks louder to an auditor than the presence of this standard documentation.

If the above items and cautions seem simple, they should be!  The problem is that if an auditor finds that any of these “basics” are missing, they know that you are more than likely to be deficient on bigger items as well.  In other words, your little issues have now created a big problem. So, don’t give auditors or claim examiners more reason to go through your notes with a fine-toothed comb.  Instead, be sure your documentation covers the basics, is legible and well organized enough to make a good impression, and essentially communicates to your auditor that they are wasting their time (and their money) trying to audit a good doctor like you!

Small Chiropractic Documentation Errors That Lead to Big Problems

It’s no secret that chiropractors are all fighting declining reimbursements and a growing portion of fees are being pushed onto the patient by the insurance payers.  In fact, according to Athena Health Payer View 2012, the weighted Provider Collection Burden increased by 7 percent from 2010 – 2011.  In other words, your patients are being forced to foot more of the bill, which then increases the burden on you to collect it.

Because these moves are precisely calculated by insurance companies, chiropractors tend to feel powerless at times. As a result, we often sigh and continue to take the beating. And while reality dictates that we cannot win every battle, we can minimize the damage done to us by insurance payers by learning to recognize which ones will give you the biggest headaches ahead of time.  Certainly, you could easily say that no insurance plan is ideal, but with a little bit of homework, you’ll see that certain plans spell more bad news than others.  Here’s how to spot the rotten apples:

Examine Contracts Carefully!

Although it is seldom done, chiropractors can often smell the El-Stinko insurance plan by simply reading the fine print in the contract. In fact, you are making a major mistake by simply signing contracts – even renewals — without even bothering to read them. This may sound like common sense but unfortunately, from the number of chiropractors who actually do this – the good sense to read the contract first is not all that common.

Best Practices:

• If the insurance doesn’t let you see the whole contract up front including the fee schedule that should be a big fat red flag telling you to prepare to be abused down the line.
• Similarly, if you are asked to pay a $150 application to join the network, but haven’t yet seen the fee schedule and what the network restrictions are — put your checkbook away.
• If you haven’t heard of the insurance that is asking you to join, ask to see a list of major employers or groups they have in their network (in addition to the fee schedule).  Unfortunately, over the last several years we have seen a rise in “mystery networks” that exist on paper but have no actual patients or employer groups.  The only thing these networks do (often with PI cases) is get you to agree to discount your fee.  Then, when you do get a good paying PI case, you suddenly discover that, due to your participation in the XYZ Ghost Network, your full fees are reduced to their “contracted rate.”

Compare the Fee Schedule

If you’re reading the contract and willing to further investigate the plan, the next step is to evaluate how much it will pay you. Look at the plan’s fee schedule and compare it to your current payer sources. Is the reimbursement higher? Lower? About the same? If the rates are significantly lower, you may want to toss the plan. But how low is too low?

Best Practices:

A basic benchmarking step to evaluate a fee schedule is to compare it to Medicare (which we know does not pay profitably) and to one of your best paying insurance plans. Here’s why: we already know that Medicare’s fee schedule for chiropractors is pitiful and for many of you, not even profitable. So why would anyone want to sign a contract that rates lower than that? On the other hand, if the fees compare to one of your better payers, it may not be a bad plan.

Compare Coverage

Sometimes looking at the fee schedule will not reveal enough.  You need to look closely at the coverage that the plan offers so you don’t make a superficial mistake.

Best Practices

Do the math!  For example, Let’s say the Plan Awill give you six visits that would reimburse for average services performed at $50 per visit.  You can anticipate a total reimbursement of $300 from the plan (plus whatever patient responsibility is).  Plan B covers 8 visits but will only reimburse $30 per visit for a total anticipated reimbursement of $240.  Obviously, one looks a little better on the surface, but some digging reveals that’s not necessarily the case.

Factor in your Visit Average

You may be satisfied with the rates you see in the plan’s fee schedule, but don’t accept them until you’ve seen how many visits the plan offers and compare that to how many visits your patients average.

For example, if the plan covers 12 visits and most of your patients average about 6 visits, the plan may be insufficient. On the other hand, if you normally see a patient 24 visits and the plan covers six, you are going to have the bulk of your care non-reimbursed. So you need to be aware of what kinds of patients you normally treat and how quickly you treat and discharge them.

Don’t Be Afraid to Drop an Insurance

Many new chiropractors opt to sign low-paying contracts and become providers for lousy networks because they feel some cash is better than no cash while the practice grows.

However, be sure that this move doesn’t continue on indefinitely. Make a note to revisit the contract after you’ve established yourself, because in the long term, a contract like that doesn’t make a lot of sense, and you may want to let that plan go.

Best Practices

Each year you should review your contracts and your 1099’s from payers.  Weigh the facts and make a good business decision – not an emotional one – on whether to continue doing business with that payer.  For more strategies on this, see my previous article on “How to Drop An Insurance Company.”

Insurance Contract Catastrophes – How Chiropractors Can Avoid Them Before They Happen

Of our entire 13 Things You Will Need to Change series, this post will perhaps represent the toughest challenge for many to chiropractors accept and overcome, which is why I have saved it for last. Before I spit it out, let me preface it with three quick thoughts:

a) The old revenue model, purely based on volume, is crumbling. Payers are paying less and less for adjustments and limiting care while expenses continue to increase.

b) Unfortunately, over the last decade or so, utilization has not increased; in fact, the latest stats indicated that the public use of chiropractic has either flatlined or decreased slightly.

c) Simple economics dictate that if the price of your service is decreasing, the frequency of which it is consumed is decreasing and the cost to deliver that service is increasing, you have an impending disaster in the works.

Thus, here is the single biggest change that chiropractors must make:

Chiropractic businesses must focus more on strategy and less on tactics.

Problem is, most chiropractors go about this backward.  Too many of our businesses are driven by opportunity seeking tactics. We hear about the latest rage in chiropractic (decompression, laser, nasal irrigation – whatever) and we hop right on the bandwagon and hope to ride the profit wave.

There are two fundamental flaws with the tactical approach:

1)     This causes our practice to be driven by our sales, not our strategy.  So when the inevitable happens and things don’t quite work as we hoped, we are off to the next opportunity and we drag our practice (and our staff) 180 degrees in a different direction in its pursuit.  Even if our tactics do work temporarily, we don’t know how to manage sustained growth because there is no real strategy at the core.  We end up just slapping on one tactical patch after another until our practice is a rag-tag mess of a business whose revenues ride like a roller-coaster.

2)    To survive, a tactical-driven business must stay ahead of the curve.  Success is possible for tactical businesses, but you must be an early adopter.  If you happen to be one of the first chiropractors to introduce a new technique, try a new marketing scheme or have some sort of new gadget and can figure out how to promote it, things will be good. Unfortunately, this is bad news if the game you are playing is constantly changing or the future is uncertain (as in healthcare) because it decreases the odds that anyone can actually stay ahead of the curve.  And since obviously not everything new works so well, the tactical DC will inevitably drop some good ideas in favor of some newer, but less effective ones. Even worse, this cycle must continue.  The practice must constantly strive to find the newest angle because it lacks a fundamental strategy and therefore, has no cohesive approach to anything and instead gambles its success on whatever novel idea the “wave” of opportunity brings.  Perhaps worst of all, the tactical DC is generally not a good colleague to have next door.  He is hyper-competitive by nature because his business rests on tactics and tactics generally lose their effectiveness over time or with over-utilization (because then they are no longer a shiny new object).

Why Strategy is Needed for 2013 & Beyond

So, we must re-engineer our businesses towards strategy to succeed in 2013 and beyond.  (If you haven’t watch the above video already, see how we are approaching that concept in our consulting business with our new Chiropractic Profit Launch Blueprint training).

Our revenue model must change.  Put another way — the “old school” style chiropractic ain’t going to work much longer. This will be true (and already is in some aspects) in every sense of our business.  Marketing will change, reimbursement will change, our care will change.  With healthcare in flux, we may not be able to predict the change, but we know it will happen.

To adapt to that change therefore, we don’t need more tactics that will try to keep impossibly ahead of an ever changing curve, but better strategy.

Our strategy will need to address fundamental business problems mentioned above – i.e.  declining reimbursements, decreasing utilization, increased overhead, etc. And then, our strategic response to those challenges should include tactics that address those obstacle and not the other way around.

Here’s why strategy must come first:

Let’s say we find a new internet marketing tool (a tactic) designed to attract new patients and we put it to use.  Now, truth be told, we don’t quite know if new patients are the answer to our problem, but since our tactic is so new and attractive, we put it to use anyway.

The tactic apparently works well and NP’s come in the door.  But we notice there are a few things wrong with these New Patients.  The possible errors could be many:

• You attract a bunch of bargain hunting cash patients and you are trying to increase your high end decompression cases.  They go away eventually because they found the “wrong” chiropractor.
• You attract many Spanish speaking patients but neither you nor your staff speak Spanish and can meet their wants. They go away eventually because they found the “wrong” chiropractor.
• You attract many new patients and are unable to handle the growth.  Your older patients who have been around a while begin to leave; the newer ones stay but they are less profitable, more work and don’t heed your recommendations as well as the older patients who left.

So, where did your new tactic get you? In all three cases, absolutely nowhere; possibly, you are even worse off than you started. This is why strategy must come first. Without a strategic plan, you don’t have the ability to recognize what is a good opportunity and what you should pass up.  Instead, you constantly run around putting out one fire after another in hopes that someday you will get ahead (but you get a sinking feeling that day will never come).

What Strategy Will Serve YOU Best?

Honestly, I don’t know what will work best – for you.

For some chiropractors, your strategic plan may include the need to enhance what you are doing currently to take your practice to the “next level.” This may include tactics such as adding significant additional revenue streams (By significant, I mean ones that can generate add least 5 digits. Quite frankly, most offices don’t sell enough topical pain relieving gels, back supports and the like to call this income significant) to help their clinics grow; some will need these streams to survive.

For others, you need to re-evaluate what you are offering currently and re-engineer your business.  Your actions may include take a focused, systematic approach to making sure that you are being paid for the good that you do.  For some, that may be as simple as actually billing for the services that are rendered instead of giving them away free.  Others may need to discover that you have reimbursable services that you are currently performing, but not being paid for.

Finally, some of you may discover that your practice is so completely lacking any strategy of any sort, that you may just need (or want) to blow things up and start again.  You will need to re-invent yourself and your practice in order to survive. Then you will be better positioned for future growth and profits.

(If you haven’t already, watch the above video to see our approach to these three challenges with our new Chiropractic Profit Launch Blueprint training)

One Size Doesn’t Fit All, But The Good News is…

As you can see, with the strategic approach one size definitely doesn’t fit all as those in the tactical camp proclaim.  Inherently, most of you can see through the shallowness of such claims anyway.  How can this one marketing trick truly be THE answer to all your new patient dilemmas? How can this technique solve all your profit problems and mine and every other chiropractors?

The good news is that although the strategic approach is definitely not “one size fits all,” you only need one size – yours! In other words, the approach that works best will be a combination of your style, your experience, your goals and your systems formed into a cohesive strategy that allows you to uniquely bring your service to the marketplace.

Once you’ve mastered this strategic approach, your drastically reduce competition, you inherently create excitement and demand around your passions and you inevitably feel that you are doing what you were put on this planet to do!

Fasten Your Seatbelt! The Toughest Challenge DC’s Will Need to Overcome (Part 13 of 13 Things Series)

There are two words we need to all memorize and never forget.  When we do, we become small minded about our business and, worse, our own potential.

Most of you know that I’m not quite the motivational speaker type (unless hitting you in the head with a shovel qualifies).  But this one fits the bill, so I’ll keep it short.

DREAM BIG!

Here’s why: you need to in order to thrive in practice!  None of us enter the chiropractic profession to be mediocre, but unfortunately, many of us begin exiting in that direction long before we’re retirement age.

We let the daily minutia of running our businesses begin to drag us down and slowly erode our dreams.  We settle for less with ourselves, with our patients and commonly, with our incomes.  In time, we derive less and less satisfaction from our chosen profession (no one forced you into this) and we begin to act more and more like we have a job.

Please stop.

You are not doing yourself or your patients or your family, friends or loved ones any favors with this type of behavior and lousy outlook.  Things can change but it primarily starts with the realization that you can change.

A second realization that you must have as a chiropractor is that the profession has changed and so has the marketplace.  It saddens me to see DC’s clinging to the old days and the old ways when there is still a bright future ahead.  But the only way that I can make such a statement (I’m notthat naive) is that I believe the bright future will look much different than our current landscape.

Case in Point: My Journey

Even just a few years ago, if you would have told me that a platform in which you write your thoughts and publish them online would change my business forever, I would have asked what you were trying to sell me.  Furthermore, if you would have told me that this “tool” would enable me to reach thousands of chiropractors all over the world — every week — without constant travel, I would have really wanted to hold my wallet tightly.

But what would have caused me to flat out laugh in your face would be the thought that this tool could not only do these things, but do them well.  In fact, so well that it’s impact is significant on my business.

And what would have been totally unimaginable is that the impact would also be recognizable outside the profession.

But that’s exactly what happened (see the  award & read the press release about me from Constant Contact, my bulk email delivery provider). Some chiropractors, who still are asking SHOULD I get a website? The internet has changed things more than they are willing to admit and they are a looking more like dinosaurs than they are willing to admit for even questioning that fact.

But the internet is not the only thing that has impacted change.  Take a look around.  Many of the “hottest” chiropractic techniques and tools were not even in existence a decade or so ago and if they were they didn’t yet the radar. And yet, some of you use these things daily now and wouldn’t know how to practice without them.

Long story short — Dream Big! None of the chiropractic “greats” ever got that way by thinking small.  (In fact, you can apply that same logic to most success stories in any profession or industry.)

Get a website, get a blog and get the word of those big dreams out to your patients and to the community and do it repeatedly!  Invest in yourself, your technique, your skill-set by attending seminars (I’m partial to my chiropractic billing seminars but any will do!) or advanced course work.  Know that you can get yourself out of whatever rut you are in, primarily because you are capable of change and because you are likely the one that put yourself there!

That’s all the motivational talk I can stomach myself — but, in today’s economy, in our profession and in the current state affairs, I think that remembering to DREAM BIG is not just some mumbo-jumbo.  It’s the future of our success.

2 Words Chiropractors Need to Memorize (Part 12 of 13 Things Series)

You must develop an ACTION PERSPECTIVE — the critical ability to see the bigger picture and act upon it! 

Take a step back and look at the bigger picture. It’s time to determine where your time and energy is best invested. If your personal net (take-home pay before taxes) from your practice is $250,000 or more, chances are you are already pretty good at this. In fact, you are probably at least twice as good at it as the “average” chiropractor who (according to salary surveys) makes less than half that amount. Of course, if you’re making that much or more, then you realize you can still learn and gain from each and every “gem” shared in this blog, seminars or everywhere and anywhere you can find them.  You are likely a life-long learner and have an insatiable desire to keep growing.

If you are not making the kind of income from chiropractic that you deserve, chances are you are not effectively focused on restraining yourself to spend time ONLY on the most productive tasks.  Chances are you rarely “get to” many of the projects, strategies or “gems” that could potentially be your biggest bread winners.

How do I know this about you?

First, cause I’m guilty of it myself – occasionally. But even more so because you’ve told me. Perhaps not in so many words, but by the comments that I get via email, chiropractors frequently admit they’re so busy just getting through the day that they have no time to tackle a number of projects they know could help increase practice success.

If you’re really serious about maximizing your profit, your fun and your freedom from practice, you must start here.  Without proper perspective, you are doomed to run in endless directions trying to improve your practice and eventually you will either run out of time or energy to do so. Fortunately, acquiring perspective and the discipline that it takes to act on it is a learnable skill and, in my opinion, the single biggest one that is never taught in chiropractic college.  Interestingly enough, it is also a common trait that I find in every single successful chiropractor or businessperson of any profession – no matter what their business or practice is like.

Here are a few tips to help develop the single biggest “non-chiropractic” skill of perspective:

1. Perform a 7 day time and motion study. Keep track of exactly how you spend your time, every waking moment, broken down into 10 minute increments.  You can easily do this online with apps like Rescue Time or you will need to simply log what you have been doing.

2. Make a “Wish List” of the items that you wish to do to grow your business.  These are the things you should be doing (or doing more of) but that you just don’t ever seem to find the time for.

3. Analyze your list to find the biggest rocks.  Once you have a list of everything you have been doing with your time and everything you’d like to do in your practice, then PRIORITIZE THE LIST based upon BIGGEST BANG for the BUCK… i.e., your number one “to do” should be the one you feel has the highest potential to increase your income the most.

4. Delegate Everything You Can – Get rid of anything and everything that does not truly require your expertise. It never ceases to amaze me how many docs that I see taking their own x-rays, maintaining their website, doing their own bookkeeping or even taking home the laundry for their massage therapists. Sure, some of you think you need to save a buck because you don’t have any, but what you don’t realize is that you have filled your time with activities that are labor intensive that you could easily delegate so that you can focus on higher ROI tasks.

5. Eliminate Time and Energy Suckers or Re-Design Your Life.  I’m not necessarily talking about people here, but that’s not a bad idea either.  More specifically, though, you should delegate the stuff you can and eliminate the leftovers you hate.  I’ve heard some pretty famous excuses of why docs hate their paperwork, but I’ve heard few good reasons for why they can’t delegate 90% of it out to a scribe. Similarly, if You-Stink Insurance is becoming an arch-rival of superhero proportions, why continue to play their game?  Eliminate them or re-design your practice so that you don’t need them.

6. Keep Learning – it never ceases to amaze me how the most successful docs are the ones most open to learning and the ones whose practices are in or near the toilet are the ones who act like they know it all.  Perhaps this outward arrogance is trying to hide inner insecurity that their business is flailing but regardless, it is not helpful.  I read approximately 50-100 books per year and my highlighters attest to the fact that I come away with helpful nuggets from every one.  And when I hang with my mentors, mastermind groups and high level achievers whose businesses outperform mine and most others in the room, I am always amazed how they are always asking, listening and learning how to grow their business even when all appearances show that their companies are booming.

7. Repeat:  I’m fully convinced that, along with item #6, we all need to repeat these steps continually and will never arrive at a place in our business where we just coast. Don’t get me wrong – life can get a lot easier. But I think it’s important to avoid stagnation.  Even monstrously huge companies that rest on their laurels risk being eliminated from the universe – why wouldn’t the same principles apply to you and your practice?  Instead, lather, rinse and repeat.

One Change, Big Results

So, remember, keep perspective and ACT!  I can safely say that you are very likely spending a significant amount of time doing everything but the biggest rocks. This single change in mindset and action could be the first step towards making 2013 one of your most profitable years ever.

The Single Biggest Non-Chiropractic Skill You Need Now (Part 11 of the 13 Things Series)

I’ve placed this item near the end of our “13 Things series” because, quite frankly, who knows if ICD-10 will actually happen on schedule or at all.

If you’re an ICD-10 threat follower, you undoubtedly know that the powers that be have cried wolf before.  But at the time of this writing (Feb 2013), there are some strong indications that ICD-10 will actually go forth.  Here’s why:

• There already exists a “code freeze” as far as Diagnosis codes go (ICD-9) and, except in cases, for new diseases or new procedures, there will are no new codes planned.
• After October 2013, there will be no new codes issued on ICD-9 at all.
• Any planned new additions to the codeset after October 2013 will take place in ICD-10

Recommendations for ICD-10 Training for Chiropractors and Their Staff

Even though it looks much more likely that the ICD-10 will go through, I’d have some serious hesitations about training my staff anytime before June 2013 (at the earliest), just to make sure that the ICD-10 thing will really happen on time.

Unfortunately, coding “experts” have already been holding seminars this and even last year on ICD-10.  I’m sure that is good income for them but I’m sorry –  if ICD-10 gets delayed to 2015, do you really expect your staff to learn it this year, not use the codes AND remember everything in a couple of years?  For some, even learning things in 2013 that won’t be used until 2014 is pushing it.

Wait it out.  You’ll hear the rumbling getting closer.  Then act!

Chiropractic ICD-10 Training: Too Late, Too Early? (Part 10 of the 13 Things Series)