People Process and technology and the audit
Hey everyone, Dr. Brian Capra here from Genesis Chiropractic Software and Billing Network. Tonight I’m going to talk to you about how insurance companies leverage people, process and technology to beat the heck out of us and really kick us when we’re down, take our money and use it to audit other chiropractors. People, pretty simple one actually, a lot of their work is outsourced. We’re going to talk about automation with technology where they’re able to actually automate so many things where they don’t even need people. But when they do need people and you call, who do you get? You’re actually talking to somebody in India. So what do you think they’re paying them? They’re paying them maybe a dollar an hour. They’re paying them for your team member to call them. Hopefully it’s not you because it’s even worse if it’s you. But if you have a staff member calling them, maybe you’re paying them whatever you’re paying them, 12, 13, 14, 15, maybe more dollars per hour. That’s what you’re competing against. That’s the cost that they know they’ve got you beat as soon as you pick up that phone. Just by picking up the phone, you’ve lost. That’s the simple of it. That’s people, super simple. Process, let’s talk about your process. I have some notes. So forgive me if I’m looking down at my notes. Let’s talk about your process versus their process and how much manual labor there is on your end and how much manual labor there is on their end. Remember now, you’re paying somebody 15 bucks and hour. Let’s say they’re paying somebody nothing, well very little relatively for their manual steps. Let’s look at how many manual steps you have compared to them. So manual steps, benefit verifications, pre-certification, hunting and pecking for codes, modifiers, diagnosis code links, units, ordering your diagnosis codes, all that beautiful stuff. Documentation of your visit, submitting the claim, correcting claims that were wrong, posting EOBs, submitting to secondary insurance companies, finding unpaid, underpaid and denied claims, calling and following up on those claims, submitting supporting documentation when they ask for it, resubmitting claims, collecting patient balances, which is like a job in and of itself. Think of all those manual steps. You would need somebody to do them and you’re paying them whatever you’re paying them per hour. Let’s use 15 bucks an hour as an example. Now let’s look at the insurance company’s manual steps. Again, they’re leveraging all these things. Every business is made up of three things, people, process, technology. All they do is say, “How are we going to make it cost way more in people,, process and technology for the doctor than it will for us?” Not to mention, they have unlimited money. So let’s look at their manual steps. Answer the phone, when you call to follow up for an unpaid, denied underpaid claim, if you call, or if you call for benefit verifications, or if you call for pre-certs, then the other manual step is auditing you. That’s pretty much it. Why? Let’s talk about technology. They, again, have unlimited money and they have a huge database of doctors submitting claims to their database. They have massive amounts of money to invest in technology which includes automating all those steps, automating certain steps, and then using artificial intelligence to find the doctor that’s most likely to lose an audit. They look for trends. They look for trends in claims, your codes, your documentation, your follow up on claims, denials and underpayments and all that, or lack there of, if you don’t follow up. They automate the claim receipt. So they’re not actually having somebody receive a claim anymore and then process the claim. It’s just getting to them and it’s being processed through their technology in an automated way. They’re automating the claim receipt, the denials, the payments, the underpayments, the pre-certs, the ID of candidates for audits. So they’re automating all of that. Forgive me, I just lost my page here, so give me one second. They’re automating also, identifying the candidate, the people who are most likely to lose an audit because they have all of this mass amounts of data. This technology is spitting out, “Hey, this is the list of doctors that are most likely to lose an audit.” The insurance companies are not paying people to audit you. They’re not paying auditors in most cases. Those auditors are paid a percentage of what the actual settlement will be. There’s no loss for them. They don’t lose money, other than the technology they’ve invested in, once they find you and outsource you for an audit for the most part. I don’t want to oversimplify that. There’s a little bit more details. For the purposes of this video, just want to make sure you understand that once they outsource that and that person is getting basically a commission on your audit. Then there’s the audit, and now you have costs associated with that for yourself. Obviously, just the costs of hiring a legal team, but how about the fact that they send letters to patients saying, “Hey, FYI, your doctor is being audited.” How about a new patient killer or practice killer and attrition risk for your practice where patients are getting letters from their insurance companies saying, “Hey, your doctor is getting audited.” I’ve heard stories of clients that went through audits before they joined Genesis where they actually showed up at the patient’s home and knocked at the door at night waking the children up and saying, “Hey, did this doctor do this? Did you get these services at this doctor’s office? Because they didn’t support the proper documentation.” Just showing up at the patients’ houses. You also obviously have the legal defense. Those expenses are going to climb. You’re facing losing your license because once you get audited, there always a chance that … The best case is
Checkers Vs Chess intro
Hey, everyone, Dr. Brian Capra here from Genesis Chiropractic Software. Thank you for joining again. This is really starting to gain steam here. If you’ve been watching the other videos you know where I’m headed. If you haven’t, go back and watch at least the past six or seven videos. This is really going to start to come together for you. So there’s a very famous quote. We use it all the time in chiropractic. “We can’t solve problems by using the same kind of thinking we use to create them.” This is no different. We used to think that… Well, for a while, there was no insurance. Then we thought it was a great idea to take insurance, right? The Mercedes 80s, we’re making lots of money, so that was a good idea. Then we thought it was a great idea to go all cash. And somehow that made us more principled than other practices. Now we know that there’s actually no such thing as a cash practice. If you watched the other videos you’ll know what I’m talking about. I won’t reiterate that right now. But, yeah, there’s really no such thing as a cash practice as far as what you need to do. The truth is, we just need to do what’s right as doctors. And what does that mean? We need to document our visits. We need to code our visits and charge patients accordingly. And then we have to collect everything that is rightfully ours, whether that’s a cash visit or insurance visit, no matter what the case may be. This is not about collecting more money. This is about what’s doing right. This is about doing what’s right. So, so what? We didn’t get to make the rules initially, right? But we have to use our experience to learn a better way, just to start thinking differently, just like Einstein said. Just start using our brains, and take a step back, and not make rush, emotional decisions. Go insurance, go cash, what have you, all of the time. Every time you rush in one direction or another, what happens is, ultimately, our profession, our doctors, wind up in more trouble, and we don’t want that. We just want to do what’s right. We want to do what is going to free us up, what we love to do, take care of patients, serve more patients, save more lives, turn people onto chiropractic and what it really does for people, be able to serve that purpose in our lives. This is a nuisance, right? For sure, documentation, coding, billing, all that stuff is a nuisance. But there’s a better way to do it all. First it starts up here. We have to start thinking differently. Every business… So this is part of that. Every business, especially the biggest businesses in the world, every business is made up of only three main components ever, three, okay? One, people, I’m not going to go into details right now, but I’m going to go into this later videos, people. Two, processes. Three, technology. So our goal is to beat insurance companies. And as we know, state boards… Go back and watch the other videos so you know what I’m talking about. You want to beat insurance companies, you want to beat state boards at their own game. We’re not going to play tricks, we’re not going to use shortcuts, but we’re going to beat them at their own game. And if we’re going to win, here’s a thing, they’re playing… And by the way, state boards are really just a proxy for insurance companies in a lot of ways, okay? But they’re playing chess, while we’re playing checkers. So, if we’re going to beat them at their own game, we have to start playing with chess pieces. And, again, those three main pieces are people, process, and technology. So in the next few videos, I’m going to talk about the three main pieces, and go into more depth of what that actually means in your practice. What does that actually mean when you’re trying to win? And what seems like an insurmountable goal, we’re going to do it. We actually are already doing it. Just got to understand the principles here, just like chiropractic, it’s a principled thing. It’s never wrong, okay? So we’re going to use their own methods and methodologies to beat them at their own game. We’re going to use coding and documentation. They made the rule, we’re going to use it to beat them. I’ll get into more depth about that. We’re going to use technology, their technology, against them. And we’re going to use their manpower, their people, against them. So stay tuned. This is a short video tonight. I’m going to go into more depth about this. So stay tuned. And this is where it really starts to get good, if you ask me. I’m biased, this is my own video. But this is where we’re really going to start to talk about it. These are things you’re not hearing about. Genesis Chiropractic Software and Billing Network, it’s not about software, it’s not about billing, it’s about giving you freedom from these shackles of insurance or cash or what have you, constantly worrying about whether or not you’re going to wind up in trouble for what you’re doing. I’m going to start talking about the principle we’ve used and how we’ve used it. And I’m going to start talking more about Genesis in these videos, so don’t be alarmed. I’m not trying to just self-promote, but I just want to help you understand how we’ve done things and how some of our doctors are benefiting. So I appreciate you joining, appreciate you watching these videos. Thank you, everybody. I can see you guys joining and liking and thumbs up. Please keep on coming on. Comment if you would, I would appreciate that, and share this with your friends. Thank you
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
How they are legally allowed to collude
Hi everyone, Dr. Brian Capra here from Genesis Chiropractic Software. Today I’m gonna talk to you about how insurance companies are actually legally allowed to collude against we chiropractors to actually keep our money, gain interest on that money and use that money to actually use it to audit more chiropractors, taking more money back from us. Last video I talked to you about how insurance companies actually make more than 50% of their profit on interest. Interest on your money. So they should’ve paid you right after you adjust that patient. There’s nothing technically preventing them from actually paying you at the time of service. They do not and then it, in most states, they have usually about 30 days to process a claim. Not necessarily pay you, but process the claim, right? They have actually been able to rig the laws in their favor to do this. They are actually protected by the law. I am going to share with you some secrets I have learned over the past 15 years while running a chiropractic billing software and chiropractic billing service company. I hope you enjoy this little nugget. So why is it that on Wall Street, way more complex transactions happen every single day, but yet it’s the law that everybody involved in those transaction must be paid before the end of the day. Why is it that the law on Wall Street, but not for us or we? So, there’s a very simple uh answer to that which I can’t bel- I couldn’t believe it when I found this out. It turns out that insurance companies are legally allowed to collude against physicians. So, it’s not really just us, it’s everybody. Every physician. The, actually the entire healthcare uh, profession or industry. Insurance companies are allowed to collude. We’ve heard a lot about collusion these days, right? Um, you know in politics. This is actually real collusion. This actually happens and it’s, by law it’s on the books. It’s, it’s no secret out there. As a matter of fact, if doctors were to all get together, if every chiropractor in the country were to get together and say, “From now on, adjustment is for whatever code, is $60.00 and we will never take less.” That’s actually illegal. That’s called a monopoly, right? You may remember Microsoft went through a massive what’s called antitrust case back in the day when they were seen as having a monopoly on the personal computing world, right? Um, it’s, it’s a real thing in a uh, capitalist economy that a company by law cannot monopolize an industry. They can’t be the only provider of a good or service and once they do that, they have so much power that they have full power over dictating the price of that good or service. So that’s, that’s against the law. It’s called antitrust law, it’s very well documented, you can Google it and you’ll find a billion different antitrust cases. It’s very important for it to be there in our economy. Um, so what insurance companies have done is the opposite of, of what is a monopoly. A monopoly again is provide, is being the only provider of a good or a service, product whatever, what have you. Inscur- insurance companies are the opposite of that. There’s a word for it, it’s called an oligopoly. Google it – oligopoly. Um, and what you’ll notice is that, that’s when there’s only one buyer of a good or a service. Right now, over 70% of lives in this country are covered by three insurance plans and you’ll probably know if you’ve done any reading on this, every time a little insurance company pops up, they get gobbled up by one of the big dogs out there. And in doing so, since there’s only one buyer out there of chiropractic adjustments if you would, one payor, um they dictate the, the the price of an adjustment and obviously you’ve seen what happens when that, when that’s the case, your payment or reimbursement continues to go down over time. God only knows what would happen if we had a single payor system um, and left it all up to the government. ‘Cause here’s what actually happened. So, we wanna know why we don’t get paid right after our adjustment when technically that could happen, um, and probably save everybody a whole lotta money. And why the insurance companies want to be able to wait 30 days to process a claim and then have a denial process and hopefully you never remember to, to get that claim, to follow up on denials… Hopefully they make the co- the process so complicated, you never even submit the claim to begin with. That’s actually happening. We’re gonna get more into the tactics that they actually use to make the, to drag out the timeline for a claim to be processed in my next video, we’ll go into very specific tactics. In this video what I want you to understand is that it’s actually legal for insurance companies to collude. Why do they wanna collude? They wanna control the market, gain the profit and continue to use that money to reinvest in their own company and in lobbies. Once they have the lobbies, once they have the collusion and the power, they lobby to gain the law and actually legally in 1945 gained one of eh the only industry or one of the only industries um exempt from antitrust law. So insurance companies are one of the few and only industries in the country that are exempt from collusion. The antitrust laws that everybody else in every other company has to abide by including chiropractors and physicians, all physicians across the country cannot do what insurance companies do to us. It’s a pretty amazing fact. So, what do they do? They can collude, they consolida- they collude by consolidation and gain power. Once they gain the power, they can