When They Know Why, They’ll Comply!
PRACTICE
MANAGEMENT
Effectively Explain Medical Necessity to Patients
Kathy Mills Chang
MCS-P, CCPC
When a practice begins fine-tuning the processes of compliant billing, effective documentation, and meaningful clarity of definitions, such as medical necessity, those changes may seem overwhelming, especially as you, the doctor, communicate them to patients.
Remember, our patients aie used to simply presenting an insurance card, making a copayment, and heading out the door. You can help them understand that episodic care with a beginning, middle, and end will likely qualify for third-party payment toward at least a portion of the patient’s bill, but that other kinds of care will not.
The following scripts aie examples of encounters you may have with patients as you improve your processes and procedures. All team members should become familial' with these examples and practice them as a team so that everyone understands their responsibility in helping patients with this new “language” of medical necessity, which will make these scripts come naturally.
As with any change, begin with new patients, and then, as you can, go back and work with existing patients, first through réévaluations and then your day-to-day patients. It’s a simple way to achieve full implementation in a reasonable period.
Following aie key milestones in the doctor-patient relationship that require extra attention:
New Patient Consultation
(Set the tone right away by helping patients understand that you need their description of their progress—or lack of progress—in returning to optimal function to document their care for third-party payment.)
“I’m going to ask you a lot of different questions today, and I’ll need your help so I can have the information your insurance company requires. I want you to know I’m concerned about the amount of pain you’re having, and we’re going to work rapidly toward relieving that pain. However, your insurance company provides coverage when we can document how this problem affects how you function. So I’ll be asking you questions about how your condition interferes with your personal relationships,
household and recreational activities, and your work.
“For example, you indicate here that you normally like to walk every morning, but today, you were unable to bend over to put on your shoes. That’s a functional limitation. In fact, if you only complain of pain and no functional limitation, you may not be entitled to full coverage of all the care you need. So bear with us while we dig a little deeper to get to the bottom of what’s affecting your function.”
Report of Findings (ROF)
(Use this opportunity to not only explain what you’ve found during your initial visit data gathering, but also to lay out the expectations of how things work in your office.)
Explain how episodes of care work: “As you experience a return to health and better function, there will be ups and downs and good days and bad days—times when the aches and pains aie a nuisance and also when they’re hardly noticeable. It’s very important that you tell me not only where it hurts on each visit, but also how that affects your daily activities. We’ll ask you about the specific functions we’re measuring so we can document that.
When your improvement in function begins to level off, we’ll know we’re approaching the end ofthat covered episode of care.”
Use this opportunity to introduce maintenance care: “I also want you to know that when we reach that point where your functional improvement begins to plateau, you’ll be released to what’s called ‘maintenance care,’ which means your insurance will no longer cover your visits. It’s an important phase of your care, but they expect you to cover those costs.”
Prépaie them to pay: “It’s our policy here to never tum a patient away due to the inability to pay, so we have wonderful financial plans available to help ensure your care fits into your family’s budget.”
Importance of the reexamination: “We’ll be doing periodic reexaminations throughout your treatment plan so we can measure your progress, determine your need for further care, and document that the care you’re receiving is helping improve your function and not just reduce your pain levels. This will also help assess how you’re moving toward reaching those functional goals we set at the beginning of care.”
Explain how to identify medical necessity: “I also want you to know that when you’re on our ‘maintenance plan,’ any time the doctor feels your function measurably decreases and (he or she) believes (he or she) can get you back to the level of opti-
mum function, (he or she) will immediately put you back on an active treatment plan, and we’d expect your insurance to begin contributing again.”
Anytime we strive to make important changes in the manner in which we practice, it’s going to be hard on someone. In addition to new patients, you likely have existing patients who’ve been used to “popping in” when they hurt, dictating when you bill insurance or expecting you to submit every single visit, even monthly maintenance care, to the carrier. They don’t understand the risk they’re asking you to take to meet these expectations. These scenarios offer great opportunities to educate and institute new processes.
When patients know better, they do better. Give them context and help them understand today’s healthcare enviromnent as it affects their claims and third-party payment, and you’ll enjoy a better relationship with your patients.
Kathy Mills Chang is a certified medical compliance WjPnH specialist (MCS-P) and certified chiropractic profesBjr^|3S sional coder (CCPC). Since 1983, she has provided '^B chiropractors with reimbursement and compliance ’ training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 15 at KMC University and is blown as one of our profession ’s foremost experts on Medicare. She or any of her team members can be reached at 855832-6562 or infofifKMCUniversity.com.
