Medicare - Should you do Re-Exams within the first 2 weeks?

Today I was asked if it is true that you must do a re-exam on a patient within two weeks of them starting.  Here was my answer.

So 2 things. 

1. What codes, modifiers, re exam frequency, etc get me paid fastest and the most
2. What happens when they want a different code, modifier, etc.  How will effect my payment and how will I know.

The later, I feel, is the bigger question. If we look at this from the principle of "their main goal is to delay payment", we can see they set these rules up to be complicated, creating delay. More importantly so they can change the rules without you knowing and in turn, create more delays.  If you look at this through chiro colored glasses you quickly see that what me need is not the quick fix of the week, the magic pill/code/billing trick, we need a system that is self regulating.  We need a system that is like an immune system against insurance company antics. 

Now, insurance reimbursement, coding, billing, compliance, documentation are part or the billing topic.  The bigger topic is overall practice profitability.  Many other things cause practices to lose profit.  The typical way a doctor combats this is hire a biller, by a scheduling system, buy a note system, hire a compliance expert, etc and then use those systems independently without sharing their knowledge with other practices.  They treat each problem independently.  This is a very mechanistic approach to running a business. Today we have technology that allows us to apply a more vitalistic approach.  In reality what we need is one system with a central database so that what is learned in one practice can instantly be applied to all practices on the network.  When, not if, Medicare tweaks a rule we learn it, build in a validation that turns red as soon as the doctor makes the mistake, and prevents it from happening ever again, in any practice using the system.  We apply it to the central system so ALL providers have this instantly!  That same system measures patient compliance to care plans, no shows, products sold, visits with documentation, audit red flags, effectively controlling and coordinating all aspects of practice profitability.  Since the database is centralized all aspects are improved incrementally and the progressive improvements are shared across every provider instantly.

So again we need a immune system against insurance company methodology but also a CNS that controls an coordinates all aspects of practice profitability.  Why?  To save more lives. 

To answer your question about re-exams, yes, I have heard where this has caused problems in some, not all, cases.  My concern is not the once off little games Medicare might play.  It is understanding the environment we are in.  The game that is being played.   When they understand the principles they can see the solution as well as see the bigger picture more clearly.  If they do not I think they will always chase the quick fix, ironically.

One last important point to add.   If you understood this you realize that the only way to learn what the insurance company has done is by seeing it in data.  A huge spike in Medicare denials might tip us off that something is up.  The there would need to be research into the problem and then technology development.  Then and only then everyone benefits.  So it is true that someone needs to jump on the grenade for the greater good.  There is no way to predict who it will be.  The only question is if you are choosing to fight alone and keep what you learn to yourself or share what you learned with everyone else and visa versa.