For starters, I agree with cartoonist Walt Kelly on enemy #1: "We have met the enemy and he is us." After that, most DCs would list new patients, the economy, insurance reimbursements, high deductibles, paperwork, patient retention or a variety of other gremlins as their most frustrating daily foil that causes headaches, reduces profitability and decreases the quantity of satisfaction in practice. All those items are valid obstacles, but none is enemy #2.
The Enemy Is Winning Battles Without a Fight
At this point, you may think that enemy #2 is health insurance. You are close, but not correct. While some may view insurance as all sorts of evil, the fact remains that we freely choose to accept health insurance in order to make our care more accessible and choose to accept the reimbursements that go with that insurance. What we do not fully understand are the "strings" attached to those reimbursements from an insurance payer. And that is where enemy #2 lurks.
This set of strings – not insurance itself – is our second most dangerous enemy because it represents an almost unfathomable number of hoops that one has to jump through to get paid. It is ever-changing – what was good yesterday definitely does not apply today. Its "secrets" are not easily found and challenging to apply correctly, even when you do find them. Because of this, enemy #2 is able to win many battles without a fight.
Why the Payer Policy Updates Is Your Greatest Nemesis
Have you guessed the "strings" to which I am referring; the ever-changing "hoops" through which you must jump? Here is your answer: The payer policy update is your greatest nemesis (other than yourself). This is enemy #2.
Specifically, payer policy updates give insurance companies the ability to change their own reimbursement rules as often as they wish and according to their own consideration of evidence. Payer policy (AKA "medical policy") updates can look at a body of research and suddenly declare a procedure "investigational," even though it was previously a covered service. The medical policy also has the right (via your provider contract) to dictate how you are to care for your patients by indicating which diagnosis codes are "acceptable" and which ones are not payable for certain procedures, services and products. Failure to adhere to payer policies can get you audited for post-payment reviews, disciplined for not following their guidelines or kicked off insurance plans altogether.
Keeping Up With Payer Policy Changes
Perhaps the most difficult part of navigating payer policy changes is because they both constantly change and are different for each payer. Many payers review and update medical policies quarterly. There is no set schedule, uniform format or standard to which payers must adhere in defining their medical policies.
Let's explore this in practical terms: If the average chiropractor interacts with a dozen different payers on a regular basis (Medicare, BCBS, Aetna, Cigna, etc.), they have a dozen different entities to watch for payer policy changes. If changes occur quarterly, the chiropractor and their staff need to monitor 48 different changes in a given year. That's bad enough.
The truth of the matter is that every medical policy contains dozens of items that may be changed. Simply put, each one of your services is going to have a separate medical policy you need to be aware of. For example, each payer has a policy on chiropractic and how it covers spinal manipulation. They also have a policy on modalities for procedures such as ultrasound, electric stim, etc.; a policy on physical therapy for services such as therapeutic exercises, neuromuscular re-education, etc.; a policy on X-rays, orthotics, cervical pillows – you get the idea.
The Bad News and the Really Bad News
In reality, then, it's not 12 payers you have to watch four times a year for 48 potential changes. It's 12 payers (or more) you watch four times a year for 48 potential changes of perhaps two dozen (or more) different procedures, services and products. Now, do the math: 12 payers x 4 times a year changes x 24 procedures, services or products = 1,152 potential payer policy items to monitor each year!
If that's the bad news, here's the really bad news: Multiply those 1,152 items that need to be monitored by the fact that each one represents a patient for whom you wish to get paid. (After all, if you don't want to be paid, there's no need to pay attention!) Be honest with yourself here. How much attention have you been paying to those newsletters you receive each month from your insurance company? What about those bulletins from Medicare? How often do you go online to check a payer's policy updates, or read their provider manual?
And yet, if you so much as submit one claim for a service that is considered investigational, a procedure for which you did not follow payer policy guidelines or a product that has recently changed its status to non-covered according to a medical policy review, you risk getting your claims denied or having to refund money already received. If you are declared a repeat offender, you may be subject to disciplinary action or be removed from the insurance panel altogether. Can you see now why I believe the payer policy update is enemy #2 in chiropractic?
The Payer Policy Target – Not Just "Fluff"
Some of you who have been blissfully ignorant about this topic may think that such a weapon is only aimed at "fluffy" targets that are of questionable value, "woo woo" or only utilized by fringe chiropractors. You may feel safe with your "proven" techniques and "time-tested" procedures that have been demonstrated to work and are reliably reimbursed. Think again.
The payer policy is a precisely calculated, intentional hoop aimed at increasing insurance profitability, and is thinly veiled in the cloak of all things named "medically necessary." Strong words, I know. But how else can you explain chiropractic techniques that are declared "investigational" because of a paucity of evidence, despite the fact that these same techniques can claim more published literature backing their efficacy than other techniques "approved" for reimbursement? How can you explain procedures that are suddenly declared "experimental" after decades of being reimbursed and no new evidence introduced into the equation? How can you explain the randomness (or inaccuracy) of medical policies that completely contradict the CPT, expert opinion and common usage of certain codes, and claim that the change was made "according to the CPT guidelines and "industry standard" practices?
Here are a few examples. Most payers have a list of a dozen or so chiropractic techniques that are all non-payable (many of us probably use at least one of them). At the end of 2010, several big-name payers including Aetna, UnitedHealthcare and several BCBS subsidiaries all changed their policies on traction. In August 2011, another BCBS subsidiary resurrected an 11-year-old medical policy and started enforcing its coding interpretation to begin denying physical medicine (rehab) services.
Where were all these changes made? You guessed it! And these are just a few examples of the sudden, unsubstantiated or downright sneaky strategies insurance companies employ with their payer policies.
"Industry Standard" Practices or Profits?
The only logical explanation for the lack of logic in medical policy updates is this: The "industry standard" practice for the insurance industry is to generate as much profit for the payer as possible. It's a simple equation: If insurance increases the number of subscribers who pay premiums and decrease the reimbursements to the providers who provide the services, what is left in the middle is profit. The more they can increase premiums and decrease reimbursements, the bigger the profit.
Insurance companies are smart. If they increase premiums too much, they lose subscribers. If they decrease reimbursements too much, they lose providers. But if they change the rules (payer policies) when no one is looking, then it is our fault for not paying attention to the rules and not properly earning our reimbursements.
Avoiding Payer Policy Problems
The best defense against problems you will encounter due to payer policy changes is education. You must take an active role in becoming aware of (1) what your payer's policies are; (2) how you may need to change your procedures to remain compliant; (3) how the policies may affect your bottom line if you are unable to be reimbursed for services you typically provide; and (4) when payer policies change.
As illustrated, with the potential number of items to monitor, this certainly is not a simple process. I can verify that alerting my consulting clients of these changes is never-ending work. The good news for you is that most of you are only monitoring one practice. (To assist you in this process, I am willing to share what I use with my own clients to help keep tabs on these changes. Send me an e-mail at
noting that you read this article in Dynamic Chiropractic, and I will send you a copy of the "Payer Policy Update Strategies" I utilize.)
In the end, we still have to face enemy #1 (ourselves), but not that you're aware of enemy #2, a lesser known, secretly powerful adversary we also have to conquer, you can take steps to win this battle in your own practice – for the good of your business and your patients.
Dr. Tom Necela maintains a private practice in Washington state. He is also the founder of The Strategic Chiropractor, a consulting firm for chiropractors. Dr. Necela can be contacted with questions or comments via his Web site, www.strategicdc.com.