Author Archives: Lisa Barnett

Insurance Network Participation: Knowing When to Opt In or Out?

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Have you every wished there was an easy way to make sense of the labyrinth of insurance networks out there?

Should you be in? Should you opt out?

Below is a guide for you and your staff to follow to help you decide whether pursuing a specific insurance contract, and staying in, is worth your time and investment.

First, determine which companies you are in network with. Do you have a contract? What are your obligations as a provider? Are you getting reimbursed what the contracted fee schedule says it will reimburse? Do you have a profile set up with the National Council for Affordable Quality Healthcare (CAQH) universal provider database and is the information current, and reviewed and attested quarterly? There is no charge to create and maintain your profile in this credentialing database.

Second, make sure you know if you are currently enrolled in Medicare and if you are a participating or non-participating provider. Are you also currently enrolled as a provider in your state’s Medicaid program? Is your organization/group also enrolled?

Third, audit your patient demographic. Run a report in your practice management software.

  • What percentage of your reimbursement is coming from insurance?
  • What percentage is coming directly from patients?
  • Which payers are you mainly seeing patients from?
  • Are you finding that patients are requesting you be in network with a certain company?
  • Who are the main employers in your area insured with?
  •  Are you enrolled as a provider with the Veteran’s Administration in your area?

Fourth, make a list of Insurance Networks you are with to clarify if questions arise later regarding participation. Review if you have fee schedules and contracts on file.

Once you have a grasp on the above, you’re ready to determine if you need to pursue network participation with additional companies. Treating this like a sales or business venture, you’ll want to have insurance companies coming to you and requesting you to be in their network. Remember, it is to their benefit and their obligation to keep their paying policyholders happy. Patients should feel free to call their insurer requesting you be on their plan. Patients have done this, and outcomes have been successful. Why?

Because the worst phone call that an insurance company can receive is from an upset policyholder who can’t afford to see their favorite doctor who is helping them because the doctor is not on the plan.

Things to consider prior to enrolling in a plan include:

  • What is the reimbursement rate?
  • What percentage of the approved charges are taken out for contract discounts?
  • Is there a fee to join?
  • What are your obligations as a provider?
  • Do they want you to participate in their workers compensation, PI programs? (In our experience, opting in to the WC and PI products means no steerage to you, and cut reimbursements).
  • Are there pre-authorizations required prior to care?
  • Is there a visit limit?
  • What is the initial credentialing and re-credentialing process?

Now, you are on all the plans that are making your pocketbook and your patient happy. What do you need to do to maintain your in-network status? You will need to notify a payer with updated clinic information anytime there is a change in information you submitted at enrollment. This includes address change or adding a new provider to the office.

Many of the larger commercial payers such as Blue Cross, Humana, United Healthcare/Optum Physical Health, use CAQH to approve your re-credentialing. Those who do not will send a written communication via mail or email letting you know your recredentialing is coming due and will include the applications and instructions. Make sure to track these dates in your insurance spreadsheet.

You will also need to make sure you are tracking re-credentialing timeframes for each insurance company. Typically, the recredentialing process for commercial payers is every three years but since your enrollments with each payer fall on different dates, your re-credentialing due dates will vary. Your Medicare re-credentialing is every five years for both individual and group enrollments. Re-validation with Medicaid programs is typically every three to five years, depending on your state’s standards. For example, it is every three years in WI and every five years in MI.

We’ve just touched the surface of network plans and credentialing. Email me for assistance with how these processes work for your practice.

You may reach me at lisa@pmaworks.com

Lisa

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Increasing your collections through better billing and documentation

Ask Lisa: Benefits Verification: Because Guessing Is Expensive

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chiropractic assistant verifying insurance benefits for patient

In today’s healthcare landscape, verifying a patient’s insurance benefits is more than an administrative step – it is a critical safeguard for both the patient and you. Benefits verification ensures that coverage details such as eligibility, co-payments, deductibles, and authorization requirements are clearly understood. When done accurately and promptly, this process lays the foundation for transparent care, financial clarity, and trust.

For your patients, unverified benefits can lead to unexpected bills, delayed treatment, or denied claims long after services are rendered. These surprises not only often create stress at moments when patients are already vulnerable, but become a compliance issue with regards to the No Surprises Act. Verifying benefits in advance also empowers patients with accurate information about their financial responsibility, preventing fears about surprise charges.

From your perspective, benefit verification reduces claim denials, improves your revenue cycle management, and supports effective, functional operations. It bridges the gap between clinical care and financial responsibility, ensuring that your services provided align with billing requirements. Ultimately, verifying benefits is not just about reimbursement, it is about protecting patients, strengthening provider-patient relationships, and promoting a more transparent and sustainable practice.

The best time to verify benefits in the chiropractic office is either 1) before the new patient’s Day 1 if you obtained their insurance information when they called or came in to schedule, or 2) After the patient’s Day 1 visit and prior to their Day 2 visit. This fosters continued trust and adequate time for your one-on-one financial consultation. You’ll also want to verify benefits if the patient has a change in insurance during the year.

Best Verification Methods: How to Verify Benefits

  • EHR/Clearinghouse: For a minimal extra monthly fee, verification of benefits feature is available for immediate output through your EHR or clearinghouse.
  • Insurance Payor Portals: Using specific payer websites provides the most up-to-date, detailed, and accurate benefit information, often surpassing phone checks.
  • Phone: The most reliable method for complex or high-cost services, enabling confirmation of specific benefits, authorization requirements, and obtaining a first name and reference number for the call.

Be ready to provide the following information:

  • Patient Name
  • Date of Birth
  • Member ID
  • Group Number (if applicable)

Some Coverage Questions/Criteria:

  • In-network or out-of-network status of provider
  • Annual or visit limits (if any)
  • Deductible amount and remaining balance
  • Co-payment or coinsurance
  • Is prior authorization required
  • CPT codes
  • Effective date of coverage and if calendar year or policy year coverage

If an appeal is needed:

When you need to appeal a benefits verification that mismatches the reimbursement on your EOB, the best method is to call the payer regarding the specific issue and provide the call reference number and representative’s name if you originally called to verify. If you used your EHR/clearinghouse or the payer’s portal, provide the information stated on the printout to the appeals representative. Focus on what you need for resolution, such as, “It appears your claims system miscalculated what we are to be reimbursed. We are expecting $XX remaining, and are requesting you resend the claim(s) to process per the member’s policy coverage.” If they paid correctly on another DOS, let the rep know this.

You may want to inform the patient of your appeal as well. Sometimes the patient will need to ultimately call to sort out a coverage dispute. If they signed your financial agreement, they’ll be more than willing to call their insurance company if they were expecting their insurer to pay a portion for their care.

Need an insurance verification form for use or to compare what you currently use in your office? Click HERE for an insurance verification form. On the house.
Questions? Just Ask… Lisa

Ask Lisa: Front Desk and Insurance Departments Hook Up for Start of New Year!

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balance scale between aesthetics and your bottom line in the chiropractic profession

Balance Between Aesthetics and Your Bottom Line

Greetings!

I’m condominium and cat sitting from December into January and am looking out of a window of natural beauty. If you are familiar with the Kettle Moraine areas of Wisconsin, affectionately referred to as “The Kettles”, you’ll deeply appreciate the beauty balanced with serene livability. The Condo complexes are built on a solid but interesting foundation of intertwining drumlins and kames of deposit sediment from glacial melts, making it challenging to keep your footing if you hike these.

Which brings me to you, and the balance between the sometimes hilly, lose-your-footing areas of your office and the beauty of it when you help a patient return to their own footing. And such is the time for your Front Desk and Insurance Department roles to intertwine at the start of the New Year!

Here is a simple New Year Checklist for your front office and your insurance departments to maintain balance of beauty and your bottom line:

1)  Obtain all patient’s insurance cards and make a copy for scanning into your practice management software. This is also the time to verify patient’s current address, cell phone number, and email address. Both areas of your office – front desk and insurance, need this information, and need it to be current. Maintain a pleasant, aesthetic reception area that is welcoming for patients and creates an amicable environment for patients, who will now be more likely to be kinder in providing you their personal insurance information. I know the difficulty this request can pose.

2)  Team up to discuss and decide who will be holding patient financial consultations post-insurance verifications on new patients or change of insurances. Remember these need to be done at the very minimum, in a semi-private, to fully-private area. Will it be the front desk? Will it be an insurance staff? CT? Will it be you, the doctor, conducting these in the treatment area? We’ve seen it done all four ways and sometimes combined. Whatever works best, with the framework of respecting and staying compliant with the patient’s privacy and finances.  What have you done regarding communicating benefits to patients up until now? Has it worked? If so, keep doing it. If not, how can you tweak this process to make it better for you and the patient? See last month’s article* on process improvement while not necessarily focusing on efficiency improvement.

3)  Working and following up on Patient Receivables. As with financial consultations, it needs to be done. Your prep work is to decide who will do the patient receivables follow-up: front desk, insurance, a combination? Consider updating your office policies to almost always collect at time of service to prevent the need for future follow-up on aged receivables.  Insurance follow-ups are best done by your insurance department. Consider sourcing out your insurance billing to someone who will do the insurance follow ups for you if you do not have internal insurance staff.  And…

4)  Make it a great, serene start to 2026!

And I have more great news for you! Our newly updated Welcome to Wellness* program is ready for purchase. As a special bonus this version includes:

  • 15 minute telephone consultation with the author, Dave Michel, on how to implement this class in your office. This includes sample versions of the most recent classes.
  • 90 Day Subscription to thePMA Members Library of over 500, helpful, customizable documents and articles.  You can read more about it here. [LINK]
  • Additional add on services for the Welcome to Wellness are also available.

We are currently in the process of updating our Patient Financial Consultation Kit for early Spring delivery.

Just Ask…

Lisa
920-334-4561
lisa@pmaworks.com

Ask Lisa: It All Goes Back to the Goal!

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theory of constraints the goal by Eliyahu M. Goldratt for the chiropractic office

I recently took a book off my bookshelf to re-read …

The Goal by Eliyahu M. Goldratt is one of my favorite business books. I love that Eli drives home being human, while at the same time having great capacity to improve systems and procedures in the workplace. As a business owner this relates directly to you.

Keep reading to learn how.

A few key takeaways from the book and how this ongoing process can help YOU improve your collections and income include:

Keeping in mind that the true goal of any for-profit company is to make money now and in the future. Two features of this are:

All operational decisions are evaluated based on whether they help achieve this goal.
Performance measurement is framed around three metrics:

  1. Throughput, or productivity (Service productivity is reflected in your NP, PV, charges, and collections stats)
  2. Inventory (making purchases intended to sell, such as supplements, pillows, exercise rehab supplies; and
  3. Operational Expense, which is money you spend to turn your inventory into productivity. This can include your practice management program and billing program’s monthly payments, maintaining and enhancing the office space, and maintaining functional chiropractic equipment such as your adjusting tables.

So, what specific actions can help you achieve the true goal for your business?

1. Identify constraints or bottlenecks in the office.

a. Look at time studies of the doctor(s) and staff. Can scheduling be done differently to open up blocks of time for more patients and/or paperwork.

b. Look for a breakdown in policies and procedures. How can it be done more effectively with better results?

2. Second, maximize and support the constraint,

a. decrease interruptions;

b. delegate tasks that are not directly clinical;

c. work on office flow for greater capacity.

3. Take note of variables. When a variable is presented such as doctor or staff
vacation and holidays , make adjustments to accommodate and still maintain your
goals.

4. Repeat steps 1 through 3, and you’ll find another constraint/bottleneck to work
through.

It may not feel good at first, but each time you cycle through the steps, according to the theory of constraints, you actually are improving the quality of your practice and its value!

Want to learn more about specific action steps for identifying bottlenecks and improving your collections and income? Give us a call. We’ve got your back. Just Ask . . .

Lisa
lisa@pmaworks.com

PS: Another great book that directly relates to this topic is “The Goal Driven Business” by Ed Petty.

Ask Lisa: Actions you can implement now to reach your Goals in 2026 and Beyond!

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It All Goes Back to the Goal!

Greetings!

I recently took a book off my bookshelf to re-read …

The Goal by Eliyahu M. Goldratt is one of my favorite business books. I love that Eli drives home being human, while at the same time having great capacity to improve systems and procedures in the workplace. As a business owner this relates directly to you.

Keep reading to learn how.

A few key takeaways from the book and how this ongoing process can help YOU improve your collections and income include:

Keeping in mind that the true goal of any for-profit company is to make money now and in the future.  Two features of this are:

  1. All operational decisions are evaluated based on whether they help achieve this goal.
  2. Performance measurement is framed around three metrics:

1)  Throughput, or productivity (Service productivity is reflected in your NP, PV, charges, and collections stats)

2)  Inventory (making purchases intended to sell, such as supplements, pillows, exercise rehab supplies; and

3)  Operational Expense, which is money you spend to turn your inventory into productivity.  This can include your practice management program and billing program’s monthly payments, maintaining and enhancing the office space, and maintaining functional chiropractic equipment such as your adjusting tables.

So, what specific actions can help you achieve the true goal for your business?

  1. Identify constraints or bottlenecks in the office.

a.  Look at time studies of the doctor(s) and staff.  Can scheduling be done differently to open up blocks of time for more patients and/or paperwork.

b.  Look for a breakdown in policies and procedures. How can it be done more effectively with better results?

2.  Second, maximize and support the constraint,

a.  decrease interruptions;
b.  delegate tasks that are not directly clinical;
c.  work on office flow for greater capacity.

3.  Take note of variables. When a variable is presented such as doctor or staff vacation and holidays , make adjustments to accommodate and still maintain your goals.

4.  Repeat steps 1 through 3, and you’ll find another constraint/

bottleneck to work through.

It may not feel good at first, but each time you cycle through the steps, according to the theory of constraints, you actually are improving the quality of your practice and its value!

Want to learn more about specific action steps for identifying bottlenecks and improving your collections and income? Give us a call. We’ve got your back.  Just Ask . . .

Lisa

lisa@pmaworks.com

PS: Another great book that directly relates to this topic is “The Goal Driven Business” by Ed Petty.

Ask Lisa – Compliance 201: Your Shield Against Bad Risk

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compliance in the health care field for chiropractorsAs a follow-up to our previous compliance articles, I thought what I’d do this month is put together a FAQ list for my dear readers and call it Compliance 201. Keep reading to learn about upcoming new requirements in the compliance/cybersecurity world to keep you at least safe-guarded when you are hit with a cybersecurity incident. Special thanks and credit goes out to ChiroArmour and Dr. Scott Muensterman for his research and presenting at the Chiropractic Society of Wisconsin Fall Experience last month on some of the content in my FAQ.

Q: What is HIPAA and HITECH?
A: HIPAA is the acronym for Health Insurance Portability and Accountability Act of 1996, in which uniform standards and requirements for the electronic transmission of certain health information were put into place and made into law. HITECH is the acronym for Health Information Technology for Economic and Clinical Health Act of 2009, a countrywide adoption and standardization of information technology to securely support the sharing of clinical data.

Q: What is Cybersecurity?
A: Cybersecurity is the practice of protecting digital systems, networks, and data from malicious attacks, damage, and unauthorized access.

Q: Is there a checklist available to ensure we are in compliance?
A: Yes. Current and Active PM&A clients have access to our HIPAA/HITECH compliance checklist, on the PMA Members Site, and compliance services are included upon request from the client.  If you are currently inactive or not a client, we can provide you with the checklist for a nominal fee. Please keep in mind your staff are already very busy, so ask yourself who is going to take on ensuring compliance at your office and going through the checklist? We can help.

Q: Isn’t it a matter of IF a cyberattack at my office occurs, not WHEN as you stated above?
A: On average there are 11 to 12 cyberattacks happening per minute in the US. So in today’s world yes, it is a matter of when, not if. And after research, it has been found that small businesses are more of a target for an attack than large organizations mainly because large organizations can put more dollars into security measures.

Q: What does Windows 10 and Windows 11 have to do with compliance?
A: Windows 10 no longer supports the security patches it used to support, effective 10/25/2025, so all of your computers must be operating on Windows 11 at minimum by this time. You CAN extend your Windows 10 protection for 1, 2, or 3 years at a significant price, but your software vendor may not honor the upgrade.

Q: I heard that there is something called an OIG Exclusions report – what is this and does it affect me and my practice?
A: The OIG Exclusions database is a reporting site listing every individual who is prohibited from seeing Medicare/Medicaid patients due to prosecution of a criminal activity, which can include being found guilty of fraud against Medicare/Medicaid, non-compliance of court-ordered child support payments, and illegal drug convictions. It is and will be a requirement to run a report MONTHLY on every person in your office including owners, subcontractors, and upon a new hire.

Here’s the link to check names: https://exclusions.oig.hhs.gov/
If you don’t see your name, that’s a good thing. Some of you are already running and checking this report due to insurance contract requirements. Save or print and file the results page.

Q: How can I confirm if my practice management program is fully compliant?
A: The website for verifying compliant healthcare software programs is down as of this writing, so for peace of mind if you are not 100% certain, call your software company or IT person.

Q: When do changes/new requirements occur?
A: As of now, no date has been set by HHS, but if you are doing the above steps and have written policies in place, you should not worry, but watch for future communications. You can subscribe to HHS email notifications here: https://cloud.connect.hhs.gov/subscriptioncenter

Q: What does Medicare documentation have to do with cybersecurity?
A: To avoid a documentation audit and subsequent potential visit from the OIG to further audits on compliance with HIPAA and your cybersecurity policies, keep your documentation and billing practices solid per Medicare chiropractic documentation standards, and make sure to securely send your notes to Medicare upon audit (and any other payer group who requests) to ensure you are staying HIPAA compliant.

Q: Can my staff be our Security officer?
A: By law, yes, but you as the doctor owner are always ultimately responsible for any attack or breaches, and payments to the government, so it is strongly recommended that the doctor owner be the compliance security officer for the business.

That concludes our FAQ for now. I know you’ll have additional questions. Feel free to reach out with those we’ll respond within three calendar days!

Stay Secure,

Lisa

References: ChiroArmour

 


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Ask Lisa: Cracking the Code – ICD-10 Code Revisions Start on October 1

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lock and key cracking the code of ICD-10 insurance codes

Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes for proper reimbursement. The translation is called the International Classification of Disease codes, or ICD-10-CM*. There are annual updates which may include deleting codes, adding codes, and minor edits to existing codes.  Keep reading for information regarding ICD-10 changes for 2026.

Although there are very few changes in 2026 relevant to chiropractic coding, the updates contain 487 new, 28 deleted, and 38 revised codes. The 2026 ICD-10 codes will be used for patient encounters from Oct. 1, 2025, through Sept. 30, 2026.

The new codes listed below may be relevant to your patient encounter:

  • Pelvic Pain
  • R10.20 Pelvic and perineal pain unspecified side
  • R10.21 Pelvic and perineal pain right side
  • R10.22 Pelvic and perineal pain left side
  • R10.23 Pelvic and perineal pain bilateral
  • R10.24 Suprapubic pain

And new codes related to socioeconomic circumstance:

  • Z56.6 Other physical and mental strain related to work
    • Workplace stress
  • Z56.89 Other problems related to employment
    • Furloughed
    • Underemployed
  • Z59.02 Unsheltered homelessness
    • Lives in a homeless encampment
  • Z59.19 Other inadequate housing
    • Poor housing weatherization
  • Z59.86 Financial insecurity
    • Z59.861 Financial insecurity, difficulty paying for utilities
    • Difficulty paying for electricity
    • Difficulty paying for heat
    • Difficulty paying for oil
    • Difficulty paying water bill
    • Utility disconnect notice due to inability to pay
      • Excludes2: inadequate housing utilities (Z59.12)
    • Z59.868 Other specified financial insecurity
      • Bankruptcy
    • Z59.869 Financial insecurity, unspecified

Coding and Billing Tips:

  • Make sure if you use a new code listed above, you relate it in your SOAP note to the patient’s condition and why they are seeking care.
  • If you bill a 98941: 3-4 region adjustment, make sure you have at least three ICD-10 subluxation codes (The M99.0X series) on the claim.
  • If you bill a 98942: All 5 regions adjustment, make sure you have at least five ICD-10 subluxation codes (again the M99.0X series) on the claim.

If you are interested in obtaining the entire file of new/updated/deleted ICD-10 Codes, click this link from the Centers for Medicare and Medicaid Services:

https://www.cms.gov/medicare/coding-billing/icd-10-codes#CodeFiles

And, BTW… we still make house calls!  Not collecting what you are owed? Something just doesn’t seem right with collections and your deposits? Give us a call to discuss if an onsite visit or video conference is right for your office.

Happy Birthday Chiropractic! Celebrate the entire month of October!

Lisa

920-334-4561

*CM refers to the ICD-10 coding system used in the United States.Sources:

Sources:

ChiroCode
Center for Medicare and Medicaid Services (CMS)

Ask Lisa:What’s up with BCBS and Therapies Reimbursement?

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Within the last two years, Blue Cross Blue Shield started requiring precertification (precert or pre-auth) on select plans for therapy codes. This came about because by Insurance Equality law they can’t require precertification for chiropractic services 98940, 41, 42, and 43, so they got around that by requiring it for many therapy codes regardless of the provider type.

If you call to verify coverage for “chiropractic”, the customer service representative (CSR) may tell you that there is no precert required for chiropractic. They may or may not understand that they have separate precerts for physical therapy codes. You’ll need to give the CSR the specific codes you want verified for coverage and limits.  You can also verify benefits and usually are able to request authorization for therapies using Availity: https://www.availity.com/providers/

Specific Claim Tips for billing BCBS: 

1)  Qualifier 431: Make sure you are entering in Box 14 OR 15, the 431 qualifier to indicate onset date within a treatment plan.

2)  Taxonomy code for chiropractic, which is 111N00000X, in Box 33. Some states’ BCBS plans require the use of a ZZ prefix before the taxonomy. Please ask when verifying benefits with your patient’s state plan what their billing requirements are. For example, is the ZZ required in front of the taxonomy code? You can add the taxonomy code for specific payers by going into your Maintenance application in your practice management software, and once added to the payer information, it will automatically generate the claim form with this information defaulted.

3)  Modifiers: I understand some of you are using XS GP for therapies and are getting paid. Great! But use this with caution. The XS modifier indicates a separate and distinct service done by a different provider than the one billing under. Better to use GP and 59 for accurate billing if one licensed provider did the therapy and chiropractic adjustment. Your 59 modifier indicates a separate, distinct service but does not distinguish between providers.

What about 98940-98941-98942? For your Medicare Advantage plan patients, make sure to use AT modifier indicating the treatment was active care vs. maintenance/supportive. BCBS usually will not pay for the GA modifier use indicating maintenance/supportive care services were provided. You’ll want to advise the patient ahead of time they will be financially responsible for their maintenance/supportive care, while presenting your cash options or packages offered. Use AT when billing BCBS Medicaid plans, all states, while the patient is under a care plan.

Where are the preauthorization requirements headed?

Here’s a recent (June 2025) article from Blue Cross Blue Shield regarding precertification requirements going forward:  BCBS News

Here’s what it states: 

“Reducing prior authorizations:

BCBS companies routinely review their prior authorization requirements, and many have taken steps to reduce the volume of prior authorization requirements in recent years. We will build on these efforts and commit to reduce in-network prior authorization for medical services as appropriate for the local market each plan serves with demonstrated reductions by Jan. 1, 2026.”

Reach out to us lisa@pmaworks.com or dave@pmaworks.com, and we can give more “boots on the ground” info for your specific state.

Lisa

920-334-4561

Please share this newsletter with your colleagues so they may benefit from this information too!

Ask Lisa: When Your Patients Need Extra Help

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payment terms for chiropractic care plan

When Your Patients Need Extra Help

Tips and Sample Policies for Financial Consideration Cases

It does happen from time to time… patients will need care but are not in a position to be able to afford care. To maintain your goals of:

  1. getting sick people well and maintaining health through chiropractic, and
  2. remaining profitable, you do have a duty to provide care to those that cannot afford care.

The two goals do not conflict.  And you do not want a patient to discontinue care because they have financial problems. Your clinic should have policies in place to enable a patient to get care – regardless of their financial ability. For active clients sample policies can be downloaded from the PMA Members Site. For all others sample policies are included in our Patient Financial Consultation Tool Kit.

Immediately following the Report of Findings, the CA should meet with the patient (the Post Report) to work out any financial arrangements, and to answer any questions that the patient may have concerning the policies of the clinic.

If the patient expresses concern over their ability to pay for the services that will be performed, go over the different fee policies that you have and see if one of these programs will handle their financial problem.

First discuss payment at time of service and prepayment options.

Here is a sample Introductory Script you can utilize:

[Patient Name], it sounds like you know how important our care is for your condition, and we want to be able to treat you. We understand that money can be a problem and know that you have to eat, pay rent, etc. I would like to set you up on our individual “Financial Consideration” program. It will provide you with the care that the doctor has outlined, at a price that you can afford.”

If the patient pushes back, inquire, empathetically, if the problem is truly a financial problem, or if they have a problem with the treatment program prescribed.

OTHER TIPS

  • Avoid writing: “(“Clinic Name) agrees to waive $100 of patient’s $200 deductible.”
  • We suggeest this be worded: “(Clinic Name) agrees to accept $100.00 from patient towards their deductible and waive any remaining deductible.”
  • When writing up the agreement, please remember to use a “per visit” amount only, rather than per week or month.
  • Please note that in talking to patients, they are not a “hardship” case, but a Financial Consideration case.

For active clients sample policies can be downloaded from the PMA Members Site. For all others sample policies are included in our Patient Financial Consultation Tool Kit.

Contact us if you need help accessing the scripts or if you have any questions!

Lisa

920-334-4561

lisa@pmaworks.com

Please share this newsletter with your colleagues so they may benefit from these services too!

Ask Lisa: Not a Robot – But Some Cool Technologies to Advance Your Practice.

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Not a Robot – But Some Cool Technologies to Advance Your Practice, and Best Software Programs for the Chiropractic Practice

My computer technology training started in the 1980s. Here we are in 2025, and the demands for and surges in healthcare technology are real. But now I write with a fresh perspective. Technology can benefit, and even potentially save, your practice while maintaining human connection and personalized care. We’ve done some research for you – keep reading to learn about some healthcare technology to help your practice grow… and a link to the best practice management software programs based on Capterra surveys.

Let’s start with the patient record or SOAP note.

Your practice management software should work for you and the patient, not against, in recording subjective complaints that meet documentation standards and best practices.

Diagnostics Technology can include the use of Goniometers, scanners such as Surface EMG (sEMG), NeuroThermal, x-ray, inclinometer, and newer traumatic brain injury scanners such as quantitative electroencephalography (say this slowly, out loud).

In conjunction with your objective diagnostics, your practice management software should be a gateway to a solid clinical assessment of the patient’s condition, care plan, and expected outcome. Is your program user-friendly in assessing a patient’s case, and does it offer you the ability to present a sound assessment and expected outcome?

Using technology to administer and record a precise adjustment can include the use of the Activator, Impulse Adjuster, SOT (Sacro-Occipital Technique) Blocks, Impulse Adjusting Instrument, ArthroStim Adjusting Tool, Pulstar FRAS Adjusting Instrument, and the Atlas Orthogonal Percussion Instrument.

How to improve patient compliance with care plans
The use of AI and algorithms to assist in customizing treatment plans that patients stay engaged and comply with is at the forefront of the future of chiropractic care.(1) Technology devices as part of a patient’s care plan to help alleviate subjective complaints can include Utrasound and Laser units, electronic pulse devices such as Shockwave Therapy (extracorporeal shockwave), and Pulse RadioFrequency devices.

Ready to learn which software programs made the top-rate list? Click on the link below to review the top practice management software programs that made Capterra’s(2) list. Note that billing and invoicing capabilities are also part of the ratings:

https://www.capterra.com/chiropractic-software/

Other than the ratings included in the link, what else should you look for before investing in new practice management software, if you’re in the market?

Stephanie Maharjan, a brand leader at WellReceived, a corporate member of the American Chiropractic Association, gives the following guidelines in researching software:(3

  1. Ensure it is compliant with HIPAA and CMS
  2. Reviews from other chiropractic practices. When assessing a new software solution, gather reviews from other chiropractic clinics. Select reviews from a few clinics and see if they still use the technology. Stephanie points out that reviews and feedback are a great way to understand areas for improvement so you can boost patient retention.
  3. Ask for a free trial or a demo before committing to new technology, so you can test various scenarios and evaluate its functionality. Assess how well the technology meets your clinic’s specific needs and determine if there are any workarounds.

Email me if you would like to chat!

Lisa
lisa@pmaworks.com

References:

  1. https://www.capterra.com/
  2. https://neulifechiro.com/technology-in-personalized-chiropractic-care/#ai-and-data-analytics-in-chiropractic-care
  3. https://www.acatoday.org/news-publications/using-technology-to-improve-patient-care-in-your-chiropractic-clinic/

Ask Lisa: Deadline nears for Blue Cross Blue Shield Antitrust Settlement filings.

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On April 29th I shared information regarding the Blue Cross Blue Shield Antitrust Settlement.  (See Link below.)

As the filing deadline of July 29, 2025 approaches we wanted to send a reminder and also some key information you need to know.

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It takes less than 5 minutes to sign up – each provider can sign up individually (it is much easier than signing up as a clinic).

This settlement includes a $224 million allocation for medical professionals nationwide  including DCs). This is 8% of the total $2.6 billion settlement, the rest is for hospitals and large groups.

Here’s what chiropractors need to know:

Key Details:

Eligibility: If you billed any BCBS plan (includes Wellmark) between July 2008 and October 2024

Filing Deadline: July 29, 2025
bcbsprovidersettlement.com+2bcbsprovidersettlement.com+2

How Payments Are Calculated: Payouts are based on your total “Allowed Amounts” (reimbursed, not billed) using a point system:

≤$250K = 1 point
$250K-$500K = 2 points
$500K-$750K = 3 points
$750K-$1M = 4 points
$1M = 5+ points

Important Legal Consideration: Filing a claim waives your right to future legal action against BCBS (including Wellmark) for any reason related to this antitrust matter.

Considerations: 
If you had higher BCBS billing over 15 years:  May equal a potentially meaningful payout that may be considered when determining participation.

When determining participation or opting out, each provider must evaluate their personal situation regarding billing history and comfort level with the legal release requirements.

Thanks!

Lisa Barnett

Link to previous article [LINK]

 

 

Ask Lisa: The Art of Navigating Insurance Network Participation

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participation in insurance networks building blocks

One of the most critical decisions you will need to make in your practice is, should you be “in-network” with a payer group, or out? It’s a tough choice, and one size does not fit all.

So, what do you do?

First, determine which companies you already are in network with, and assess.

  • Do you have a contract?
  • What are your obligations as a participating provider?
  • Are you getting reimbursed what the contract’s fee schedule says it will reimburse?
  • Are you currently enrolled in Medicare, and are you a participating or non-participating provider?
  • Are you also currently enrolled as a provider in your state’s Medicaid program?
  • Are you enrolled as a provider with the Veteran’s Administration in your area?

Additional items to consider prior to enrolling in a plan include:

  • What is the reimbursement rate?
  • What percentage of the approved charges are taken out for contract discounts?
  • Is there a fee to join?
  • Do they want you to participate in their worker’s compensation, PI programs? (In our experience, opting in to the WC and PI products means no steerage to you, and cut reimbursements).
  • Are there pre-authorizations required prior to care?
  • Is there a visit limit?
  • What is the initial credentialing and re-credentialing process?

Next, make sure you have a profile set up with the National Council for Affordable Quality Healthcare (CAQH) universal provider database and that the information is current, and re-attested quarterly. There is no charge to create and maintain your profile in this credentialing database.

Third, audit your patient demographic. Run a report in your practice management software, to determine

  • What percentage of your reimbursement comes from insurance?
  • What percentage comes directly from patients?
  • Which payers are you mainly seeing patients from and are you finding that patients are requesting you be in network with a certain company?
  • Who are the main employers in your area insured with?

Fourth, develop a spreadsheet called “Insurance Networks” to help you and your insurance department keep the information organized and up to date.

Once you have a grasp on the above, you’re ready to determine if you need to pursue network participation with additional companies. Treating this like a sales or business venture, you’ll want to have insurance companies coming to you and requesting you be in their network.

Remember, it is to their benefit and their obligation to keep their paying policyholders happy.

Patients should feel free to call their insurer requesting you be on their plan. Patients have done this, and outcomes have been successful. Why? Because the worst phone call an insurance company can receive is from an upset policyholder who can’t afford to see their favorite doctor who is helping them (that’s you!) because the doctor is not on the plan.

We’ve just touched the surface of network plans and credentialing. PM&A can provide specialized and unique advice on making the choice of which networks to join, which to be out of network, and which to run away from! We also will run those audit reports to assess if you’re getting the best bang for your buck.

Email me for assistance with how these processes work for your practice. You may reach me at Lisa@pmaworks.com.

Lisa

Ask Lisa: PMA’s New “911 Clinic Rescue” Program

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clinic rescue life preserveAre you struggling with collections, insurance demands, and general demands on your time? Or know anyone who is?

We can help. This past weekend in Chippewa Falls, WI, we introduced our 911 Clinic Rescue program.

What can our onsite programs do for you? Here is a sample list of the areas Clinic Rescue can address and help you navigate:

  • Low Reimbursement Rates
  • Coverage Restrictions and extra administrative demand such as pre-authorization requirements and records requests
  • Other Administrative Burdens distracting you from patient focus
  • Patient Affordability
  • Network Participation
    o Evaluating if an insurance contract is worth signing
    o Evaluating the risks and benefits of dropping insurance networks
  • Insurance Changes and keeping up with the latest payer information
  • Technology gaps and insurance processes

Reimbursement and Revenue:

  •  Negotiate better reimbursement rates with insurers
  • Appealing denied claims
  • Evaluating transition to a patient self-pay practice to reduce insurance reliance

Billing and Administration:

  • Reducing time spent on insurance paperwork and billing
  • Analyzing common coding errors, and how to avoid them
  • Evaluating affordable billing software and/or outsourcing options

Audits and Compliance:

  • Ensuring documentation meets insurance and Medicare standards
  • Insurance audit triggers, and how to prepare

Patient Costs:

  • Helping patients understand their insurance benefits and costs
  • Providing affordable care options for patients with poor coverage

Interested in learning more? Want to chat about your clinic-specific concerns? Call Lisa, 920-334-4561 or email lisa@pmaworks.com

Ask Lisa: Blue Cross Blue Shield Antitrust Settlement – Action Needed

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Are You Eligible?
If you or your clinic provided care, equipment, or supplies to any Blue Cross Blue Shield (BCBS) patient between July 24, 2008, and October 4, 2024, you are likely included in this settlement.

What’s This About?
A $2.8 billion settlement has been reached in a lawsuit alleging BCBS companies limited competition and underpaid providers.

Your Options:
• File a Claim: To receive any payment, you must file a claim by July 29, 2025.
• Do Nothing: You will not get any money and cannot sue BCBS over these issues later.
• Opt Out: If you want to sue BCBS on your own, you must have opted out by March 4, 2025.

How Much Will You Get?
The fund will be split: 92% to hospitals/facilities, 8% to professionals (including chiropractors). The exact amount depends on how many claims are filed.

How to File:
Go to the official provider settlement website and click “Submit a Professional Claim” to file online.

Questions?
For more details, visit the BCBS Provider Settlement website.

Key Deadline:
July 29, 2025 – Last day to file your claim. Don’t miss out.

Citations:
Settlement Information:https://www.bcbsprovidersettlement.com/Home
Application: https://www.bcbsprovidersettlement.com/Home/ClaimantAccount

Ask Lisa: Are you fully informed about your patient’s injury?

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doctor taking patient health assessment

The importance of understanding your patient’s condition

A 2013 Journal of Chiropractic Medicine article discussed a patient with benign neck and upper back pain. However, the patient had recently sustained a “hangman’s fracture” from a drunken fall but did not inform the doctor. A C2 fracture was detected through an x-ray and from further questioning.

The conclusion of the study states:

“Historical experience with similar [cervical pain] clinical presentations in established patients can influence health care providers to assume a benign causation of symptoms. Conscious effort must be exerted to treat established patients with typical presentations with the same diligence as those of new patients to a chiropractic clinic. This case illustrates that an unstable fracture and hematoma can present to a chiropractic clinic as a seemingly benign problem.”

Getting the full story of presentation to the office with your patient is critical for both the SOAP note and eventual third-party reimbursement, particularly with current pre-authorization requirements and patient reporting of subjective symptoms.

Subjective data includes the patient’s perception of their symptoms. You can begin collecting subjective data as soon as the patient first calls in for an appointment, and the doctor following up gathering this information through conversations and patient self-reports on Day One and Day Two.

Your practice management software will have an area to free-form type in a note, and here is where you can indicate why the patient is calling the office to schedule an appointment. The doctor will see this note when they pull up the patient on their computer, or you can verbally relay the information.

It is also critical upon existing patient re-exams to ask and document an additional story of what brings the patient into the office, i.e., any additional mechanism of injury. We all have them as part of this wonderful thing called Life.

Not completely confident with what the patient is subjectively presenting with? Follow your innate instincts and confirm through objective testings.

Email us for a free medicare documentation checklist. services@pmaworks.com

Need further assistance? We can help. Email “Clinic Rescue” in the subject line, to Lisa@pmaworks.com

Lisa
920-334-4561

References:
Fogeltantz, Kay, Ditty, Mark, Pursel, Kevin, (2013 September) Hangman’s fracture presenting to chiropractic clinic as benign neck pain: a case report.  Journal of Chiropractic Medicine 2013 Sep;12(3):201–206, PubMeb

 

 

Ask Lisa: Day One and Day Two Best Practice Procedures

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Greetings…
You asked for this … we heard you and have got you covered.

Here at PM&A, we consistently recommend the use of checklists, and establishing and documenting your Day 1 and Day 2 procedures is no exception. Keep reading for a comprehensive checklist to make your Day 1 and Day 2 run seamless.

Day One Upon New Patient Arrival

___1. Introduce yourself, what you do, and welcome the Patient.
___2. Provide office tour
___3. Check for questions, problems, and clear up questions as needed.
___4. Doctor Sees patient, does a thorough consultation by the use of objective tools
and history of patient such that the patient feels they were completely
understood, and all relevant facts that might relate to the patient’s current
condition(s) is learned. Adjustment is performed if appropriate and is part of your
typical clinical Day 1 process.
___5. CA does insurance/third-party benefits verification using the insurance verification
form and prepares for the financial consultation on Day 2, using worksheet.

Day Two

___6. Doctor thoroughly reviews the patient’s x-ray/objective findings before the report
of findings
___7. Doctor goes over with the patient the written Report of Findings and the patient
also receives an initial treatment plan with the necessary amount of visits and
treatments (adjustments and therapy) as best suited for the patient’s condition.
___8. Doctor reiterates “Time, Repetition, and Effort” as necessary to patient’s
successful treatment program and provides folder/packet to the patient.

In a private area away from other patients… the CA works with the new patient to:
___9.   Go over schedule of care and completes multiple appointment card.
___10. Stress keeping appointments.
___11. Communicate missed appointment make-up procedure and any fee associated
with no call, no show.
___12. Confirm doctor has discussed health care class, and invite patient and spouse.
___13. Discuss financial arrangements. This is your financial consultation with the
patient. Written financials are completed beforehand and made available to the
patient as part of their packet.
___14. Verify all needed paperwork in the packet.
___15. Stress that the patient review the written ROF from doctor.
___16. Go over check-in / check-out procedures, i.e., does the patient sign in using a
kiosk? Is the kiosk located at the front desk, or in the treatment area? Check-out
would include making sure their next appointment is on the schedule and
collecting any patient payments due.
___17. Validate patient’s desire for care & treating doctor’s skill.
___18. Ask the patient if there is anyone else in their family they would like to schedule
a complimentary consultation and exam, and if so, write down their names, and
follow up
___19. Provide educational pamphlets to give to the patients.

___20. Ask the patient if they thought of any further questions, and wrap-up, reminding the patient of their next scheduled visit.

After the patient has completed their care plan, the doctor recommends wellness care to each patient that achieves maximum chiropractic improvement, and the patient accepts the wellness care program.

Email us at services@pmaworks.com to request scripting examples for financial consultations.

Looking for additional information on how to customize the above checklist to your office? Give us a call – we’re here to help!

Lisa
920-334-4561

Ask Lisa: Best End of Year Reports to Run to Prepare for Success in 2025

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Know where your practice stands statistically going into the new year.

Happy New Year! Now that you’re back in the swing from the Holidays, we’ve put together for you a list of the most important reports we feel will prepare you for success in 2025! Have fun with running the below queries, while at the same time resolving to acknowledge the report outputs are your objective, x-ray analyses of where your practice stood in 2024.

1) Standard Financials/both month-to-month and January – December 2024 Practice stats. This will give you your new patient counts, your patient visits, your charges and your collections. What do you see month to month in terms of your high/low months? Did you do something different in the months that were higher statistically? And repeat that action!

2) Run your end of year Accounts Receivable. This is a number your accountant or CPA should ask for. You’ll need this for your balance sheet.

3) Review your Profit & Loss statements from month to month, run by either your accountant or your internal accounting software. Things to look for include:
a. Your expenses – were your expenses in line with your projected budget?
b. Your net income – were you able to pay yourself along with your associate(s) and staff salaries corresponding to livable wages?

4) Want to compare your expenses to what most chiropractic offices are doing? First, remember you want to compare you to you. But we can provide a breakdown of averages that you can look at and see where you may be high or low.

5) Accounts Receivables: 30/60/90+ days
a. Can these be reconciled? Expect 60% recovery for accounts to 60 days old; 55% recovery for accounts 60-90 days; and 20% recovery for accounts 90 days and older. The exception here is Personal Injury and Workers Compensation A/R, which are normally fully recoverable.

6) Retail Purchases – supplement/vitamin sales, pillow/therapy equipment (Durable Medical Equipment) sales.

7) Get your Sales and Use Report off your management software to your accountant or CPA by the end of January for filing the Sales Tax Report. You’ll also want to look at any independent contractors (cleaning services, IC massage therapists or other providers, snow plowing service, roofers, etc, etc) Provide their information and pay amount to your accountant by the end of January for 1099 preparation.

Once you have completed these reports and have assessed where your practice stands statistically, you can now:

• Update goals for 2025,
• Review your marketing efforts, and
• Review your retail inventory.

Need help with any of the above? Contact Lisa – I can help!

Lisa
lisa@pmaworks.com
920-334-4561

Ask Lisa: Setting Up Finances With Your Patients

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BJ Palmer had a quote: “Chiropractic is health insurance. Premiums small. Dividends large!”

Following this super quote, we have worked with offices for many years schooling them into implementing these mottos:

  • We will accept all patients, regardless of their ability to pay, but we also must operate the clinic as a proprietary business, i.e., for profit, and the patient must want the care–not just “want a discount.”
  • Each case will be individually handled and patients will receive a copy of their financial arrangements.
  • Each patient file will have a copy of the patient’s individual financial arrangements.

How does the successful office achieve these goals?

First, to comply with Centers for Medicare and Medicaid’s No Surprises Act as a covered entity, each patient will have an idea what our range of charges are and that the charges will vary depending on what is done. Explain that the adjustment charges will vary from $XX to $XX, therapies will add $XX to $XX, and exams, diagnostic tests, etc. will add to that. Typically the average office visit will be from $30.00 to $140.00 per visit. This can be shared when the new patient calls in for their first appointment, or placed on your website.

Second, determine if you will be filing claims to insurance, and if patient has a copay or deductible. If there is a financial barrier with co-pays or deductibles, work with the patient during your meeting with them so that the patient does not drop out of care for financial reasons. To stay in compliance, note any waived fees or co-payments on your financial form, indicating why they were waived (no job, too many bills). Alert payment arrangements in your practice software so that the front desk and anyone doing follow-up knows exactly what the patient has agreed to pay each visit.

The patient should already have a good idea after Day 1 from the Report of Findings and the schedule you just worked out with them how many times they will be coming in. Ask the patient if they will have any problem with this and watch the patient to make sure that they will be comfortable with the fees you are presenting (previously calculated prior to meeting with patient).

(These next sections are specific to Wisconsin offices and offer examples. However, if you find this information interesting and you want more information and are outside WI, contact us for further information.)

If you are not filing to insurance, patients are considered self-pay. Let the patient know that they must pay at the time of service for any discount given. To be successful, you cannot reduce your fee while running up patient balances.

Any discount or special fee must be noted on the financial agreements and in the computer. The financial agreement must indicate why there are special discounts given. This can be simply noted in the space provided, such as “patient discount to $30 per visit-financial hardship” or “patient has just started new job-discount given to $30 per visit”. The CA or doctor, and patient, must sign the form.

For self-pay patients who can afford care, are on a routine schedule and show up, in order to give a discount they should be required to prepay, for a package of XX visits, typically with up to a 35% discount.

With the above policies in place, you can help many more people increase their health dividends, removing any financial barriers. Implementing these steps are key to expanding and growing your practice!

If you have any questions regarding financial arrangements and/or insurance please feel free to reach out to me.

Lisa Barnett
920-334-4561
lisa@pmaworks.com

ASK LISA: The Vital Importance of the Post Report & Patient Financial Consultation

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Greetings,

In our last two webinars, we discussed the importance of patient financial consultations.

Let’s delve into why they are so important to your bottom line and how you can set them up for success.

First, changes to insurance coverage and managed care have created an environment where third-party reviewers sometimes have more say in your patient’s length of care than you do.

Second, it is important to note that the financial consultation is a part of the overall Post Report. To be successful, all steps below should be reviewed and completed with each patient, whether they are new or re-activating their care. Why a post report?

The purpose of the post report is for the staff to fully address with the patient any obstacles to the patient getting the care they need and to set the patient up for their schedule of care. This includes setting up multiple appointment schedules, emphasizing the importance of staying on the schedule of care, discussing missed appointments, discussing any needed financial arrangements, going over how to check in at future visits, establishing where the patient should turn with questions or problems, and reassuring the patient in their decision to follow through with care.

Before you meet with the patient for the financial consultation, you also have to have a clear understanding of what you want to accomplish with your financial plans for patients. Your plans need to line up with the goals you have in your office and you need to individualize the plans. Do you want a high percentage of cash, wellness patients? An insurance-based family practice? PI or Work Comp acute care rehab practice? Is the patient undergoing a financial hardship? Each has a different set of criteria for tailoring patient financial agreements.

As these become more common, you can increase your patient retention and compliance by offering more OPTIONS for patient payments. Yes, this requires more work and more follow up, but adjusting to changing business practices in the world often require changing your internal procedures and policies. Adapt and offer ways to make care affordable, then promote these options so that patients see there is a way for them to get the care they need at a price they can afford.

Our Motto: Financial Plans are Liberal; Collections Policies Are Not.

This doesn’t mean reducing your fees or giving away services. On the contrary. For example, a new car costs many thousands more than your treatment plan, but auto dealers are adept at showing the customer ways they can drive that car home today.

Standardizing these procedures will ensure that your patients feel well taken care of at the office at all times.

Questions? We can help.

Click HERE for a sample care plan and financial plan template. [LINK]