A Square Peg, Round Hole and Insurance

by John Davila, D.C.


Over time, we have all tried to force a large square peg into a small round hole and found that there are always leftover pieces that were sloughed off.  And, in order to make this job easier, we’ll need a big hammer to create enough force to ram that peg into the hole and shave off those edges that didn’t fit.
In practice this happens all the time when it comes to dealing with insurance.  If we look at all the parts involved, we could easily label them and make it applicable to what we do. The round hole is what the insurance company allows, the square peg is what we think the patient needs to get to ideal functional wellness, the excess shavings are what the patient owes the doctor for non-covered services and the hammer is the doctor’s intention.
Of all the pieces, the hammer is the most important.  This is because it is the doctor’s intention to not allow the patient to influence their decision on who needs to pay for the services billed.  But, unfortunately this happens all the time when the patient is right in front of the doctor and the patient is able to sway the doctor’s decision to bill insurance when the visit should be paid for in cash.  So, we must start with the doctor’s certainty on what it is that the patient purchased.  
This certainty must come from the policy itself and from nowhere else. It is not about anything but the policy. If the policy states that it doesn’t pay for wellness care, then it is easy to understand that the pieces sloughed off the side of the square peg are wellness care visits and should be paid for by the patient.  The same goes for exams, x-rays and therapies if the policy excludes these services.  All of these services would be considered “excluded” or “non-covered” and must be paid for by the patient due to policy restrictions.  It would now make sense that when these issues are totally understood by the doctor, it is much easier to stand firm and not be swayed to “just add one more visit on to the insurance company’s bill”.  So what, who cares! The insurance company will never know!
Billing these extra visits that are non-covered can create an insurance profile that causes the carrier to pick you out of a line up and trip the wires to launch an audit.  This would be equal to taking the extra pieces that fell off the square peg, gathering them up and pushing them down the hole, knowing full well is that not where they were supposed to go.  You can avoid this all too familiar scenario by taking the time to do two things.
First, you need to READ your insurance contracts and the policy that the patient has purchased.  Once that is done, it becomes easy to apply the policy to the situation. But, you may be concerned or even confused by all the carriers that you deal with on a daily basis.  In fact, it’s easier than you might imagine to understand the rules, because all insurance carriers have adopted “Medicare” type rules for medical necessity. Finding those rules are simple because each state’s Medicare carrier posts the definition of medical necessity on their websites.   Second, you need to improve your ability to ask the patient to pay cash for certain services when their policy is not going to cover a service, and then be willing to let patients leave the practice if they don’t want to pay.
If you are certain about what your contract requires you to do, and about what the patient has purchased, you can start to look forward to a better profile with the carriers you work with. All it takes is a little time and the understanding that all those little pieces not paid for by the carrier can trigger and audit when pushed down the hole.


Dr. John Davila is a 1994 graduate of Palmer College of Chiropractic in Davenport, IA, and practiced in the Myrtle Beach, SC, area for 13 years.  Since 2000, he has been consulting with insurance companies and doctors in private practice in the areas of coding and documentation.  His company, Compliant Services & Solutions, Inc., helps doctors of chiropractic to ethically maximize their practices, while avoiding audits and repayments to insurance carriers.  You can reach Dr. Davila, toll free, at 1-877-322-6203 or by email at [email protected] or at www.ComplaintUSA.com.

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