Episode 377 - Monday Roundtable - Payor Downcoding - Illegal or Unethical?

Hey, all right. Happy Monday to everyone out there. Hope you're having a wonderful start to your week. I'm excited because I am joined by some of my very good friends. Stephanie Howard, Scott Kraft, Terry Fletcher, Paul Spencer. Unfortunately, our very good friend, Christine Hall at the last minute had a little something that caused her to not be able to join us on the podcast today. But we'll definitely look forward to having her in the next couple of weeks. So with that said, I don't want to waste any time because there is so much to talk about today. I'll tell you what, Terry, because I have a feeling that our main topic is really going to drive the majority of this discussion. Why don't we start with what you wanted to share quickly about something going on with telehealth and then Scott and Paul, let's kind of take on that epic ambient system. And then we're going to jump into our main topic for today just so we have enough time to really hit on these three topics. So go ahead, Terry, take it away. Okay, so we did get a CMS newsroom alert and an MLN that basically said, and I know you and I talked about this on a hashtag, Terry Tuesday episode a week or so ago, that you know, they're talking about telehealth, the geographic restrictions, all that looks like they are going away as of October 1st. Now we've always heard them say for the last five years, well, unless Congress gets involved. Okay, well, they didn't say that this time. So who knows what's going to happen. They didn't even mention Congress. They basically just said everything's going back to pre COVID. But in saying that we've had this is my quick reference. There's been a couple of providers out there that are what they like to call themselves is 100% virtual. Well, make sure you know what you're getting into before you do that. If you're going to take Medicaid, for example, in California, they say, okay, we can't wait to do a site visit first and then that. And they're like, wait a minute, we're 100% virtual. What are you talking about? In California, in Texas, and in these are the states I know, Illinois, and I believe for it, I think Oregon, but Scott, you might know that they require that if a patient refuses telehealth or desires to be seen in person, you have to offer it if you're going to take Medicaid. So they have to have the option. You can't just say it's, you know, telehealth or bus. And so they didn't have a site. So they said, you can't, that you're we're not going to enroll you. That's the first thing they want to see to make sure that safety reasons, you know, you've got what they need. You're, you know, you're not in the back bedroom somewhere, you know, and all that. So even though there are some slide exceptions for behavioral health, because I know there's some, you know, online agencies that do it, for the most part, general telehealth, you have to have a brick and mortar, if you will, or physical location, should the patient want to also be seen or instead of telehealth, if you're going to take that payer. So check with your states, make sure your state knows what's going on. And you know what's going on in your state before you completely dive into a virtual only practice that you may not be able to support. That was it. Excellent. Listen, telehealth is not going away. If anything, it's going to become more prevalent, especially from a pay or perspective in auditing to ensure that they are only paying for services that fit within the description of those coverage policies, whether they're LCDs, NCDs, medical coverage policies for the commercial payers. And it's going to become more restrictive. I believe. Absolutely. I think with anything, right? Yeah. I think with anything, you know, because we don't have enough advocacy, we have some advocacy, but we don't have enough advocacy, and we don't have meaningful advocacy. So the payers will push the limits to restrict as much as possible. But at the end of the day, the thing to keep in mind, and we're going to get to this in the main topic here in just a few minutes. At the end of the day, the people who are suffering aren't a patient's. Patient care, but more importantly, quality of care is what's suffering. And, you know, again, I just I encourage people to get involved, get involved with your specialty society, get involved with the AAPC, with the MGMA, with whatever organization you hold your credentials through or you're part of, get with their advocacy group. And if they don't have one, encourage them to start an advocacy group and start pushing for legislators on Capitol Hill to do the right thing for patients. And just about money that we have advocacy for telehealth, but only about who gets to make the most money. I would go ahead Scott. No, I would just say this is like a brief bit of editorializing on my part, other than behavioral health. It's just hard for me to imagine how a position practice can run at 100% telehealth and provide effective service, how it wouldn't be seen as anything other than, we're going to make some money, but if anything comes up that's remotely serious, we're going to send you somewhere else, right? Because, you know, I think of telehealth is like, I have established provider patient relationship and I need to be seen for something relatively quickly. Maybe I have like an urgent care need where the reality is I just need, you know, an antibiotic or something like that. With this idea that you could run like a full on, full service, medical practice and never see people in person, even though they are your like identified primary provider, that's difficult for me to bad them really, frankly. And so I wouldn't, you know, and I think this will come up in some of our other topics today, but that's the kind of thing that will drive a crack down in those types of services. I agree 100% and Scott real quick. So Scott and I have a project we work on together right now and they're largely telehealth and we were talking to them. I think it was last month to just say like heads up, you know, we're looking at the end of the year, things might change. What would you do if there's a requirement for the patient to be seen in person? Because there was some language and a policy we were looking at that was talking about the first time the patient seen and all of those things. And in their situation, they have locations in each state, but it's one. So they see people all over and, you know, they're not going to be able to travel for hours to be seen in person. So then, you know, the whole discussion around leasing or owning property and getting practitioners, they have a hard time right now hiring practitioners to come into offices in certain areas. So it's something that, you know, I feel like too many people just push it off and say, well, they've extended it. They've extended it. What are you going to do if they don't? Well, and a lot of that commentary, oh my goodness, the sun. So a lot of that commentary was about, you know, this is very inconvenient for the provider, right? And it's like, well, it's not really the foundation of how we do things. Like maybe our next business opportunity is like, we were, but it's like a medical office, right? It's just an, just an exam room and some office plaza and you just rent it for like a few hours a day. Well, the 800 pound gorilla in the room just to bring this topic to a close is the fact that we've got looming provider shortages and just about every specialty. I mean, just here in the last few weeks, we passed a law and the state of Wisconsin that expanded the ability to for nurse practitioners and physician assistants to work independently of a, you know, a collaborative agreement or, you know, a physician's supervision for certain medical services. And I think, you know, the fact that they want to expand telehealth addresses this in the short term for a long term problem. All right. So good conversation on that. Let's move right into the epic issue with the ambient because again, last week, I did a couple of articles on artificial intelligence, but I really focused those specifically to the Office of Inspector General 2025 work plan and really tried to take a look at it from a view that is a little outside of mainstream. But I want to talk about what's going on right now with these ambient recording systems. So, Paul and Scott, let me, let me come to you guys and then, you know, Stephanie and Terry, please jump in and let's, let's talk through this. Well, I can start this topic a little bit, you know, being just down the road from Epic and Verona, Wisconsin, Epic, the one of the larger EMR vendors of, you know, of the United States and actually becoming the world announced that they were going to introduce a, you know, I guess a, an application is part of their larger EHR for what they call ambient scribes. Now, when I first texted this to Scott, he said, that's the worst soft rock band name that I've ever heard. But, you know, basically what it's going to attempt to do is listening. to an encounter between a provider and a patient and generate some type of AI-based summary of that encounter into some form of documentation for that visit. Now, just to let people know that this is an ambient listening by devices and by machines has been happening already. You know, when I'm in a restaurant, my phone tells me what song is playing over the loudspeaker, even though it's a Mexican restaurant, and I know none of the music that's playing over my head. We have Alexa and Google devices in our house that suddenly when we open up another device in our house that's connected to the same system is mysteriously summarizing things that we were thinking of purchasing when we were speaking out loud near that device. So this technology has been around for some time. To use it in a medical application, though, I would imagine that they're going to be numerous sign-offs from the patient in the physician's office allowing for this type of thing. You know, usually it's enough to have a patient give a different medical history to an MA and then the doctor comes in the office and it's for something completely different because they didn't want to share that info with the MA. Now we're going to say to patients, hey, let's share your detailed personal private medical information with an ambient scribe that just happens to be listening to everything that's happening in that exam room. They're putting possibly an issue with or a problem with this in the future, but it's certainly a very scary tipping point as to the doctor patient relationship. So, and to be clear, like this is already happening, right? Like this is like the number of ambient scribe notes that I read two years ago was like zero. And the number now is quite a bit and I can't tell you how many clients are asking about this. They're trying it. I think it's like the DAX ambient scribe that we see in the notes all the time. And you know, they have patient consent, but I think sometimes with the patient, you stick like nine forms in front of them to sign and form seven is like this voice listens to everything and takes the documentation. I think for me, like what I would say about the providers is similar to thriving, you need to take responsibility for what's in your documentation because we will see things in these notes. So to give you one example, I was looking at a note about 10 days ago that was a wound care note and you know, I've been doing this work for a long time, but sometimes I'll see the name of a drug and I'll say is this over the counter. And a lot of these wound care treatments that the patients are told to do are over the counter. So it's like they get the wound care and so I'm like, what am I crediting as part of this visit and the drug that the ambient scribe put into the note was I believe metalan. And I'm like, okay, I don't remember seeing metalan in a wound care note. I need to see what this is. And it's a prescription medication for I believe ADHD. And I'm kind of like way to make it right like and it turns out I believe that the provider had said metalan blue, which is a wound care treatment. And so I was talking to the provider about it and she was like, well, we use this ambient scribe and it must have recorded the wrong thing and you know, look as a provider when your notes go out into the universe, you're responsible for the contents and you know. A medication error among similar sounding medications. I have seen notes where the assessment and plan is exactly the same for like every condition. The condition is different and the the ambience drive has just been like, well, this, this two sentences I put together were really good. So I'll just plop them into every diagnosis. And I believe this provider had also, I should word this carefully, but like great care was given to the disclaimer of non responsibility that we've talked about on this podcast before for the possible errors in the note. Like that was like four sentences long right that was just like, you know, sometimes things happen and you got to look at this and you got to look at this. And you know, I think we need to tread very carefully with these things right like we need to make sure. That you may have had a patient sign something doesn't preclude them from saying they didn't understand it and bottling you up in some sort of complaint later on, but you also need to make sure that these encounters are an accurate reflection of the work that you're doing. And they signaled what your intent behind the medical necessity was so I know we're going to talk about you know coding here in a little bit. But you know how many times do we as auditors look at notes and we want to go to like a higher level of code, but then when I talk to the provider, the provider is giving me some context, which like well, I didn't really feel like this was as serious, but the note and the and the MDM chart kind of takes me to a place. And so those conversations and those intents do remain important. You know, I think one of the most important things that providers and their staff can take away from this discussion. Now I want to kind of pick Stephanie and Terry's brains on this. For me as a regulatory person, you know, not not as an auditor because I don't get the opportunity to audit charts like I used to sure. You know prior to going into a deposition or prior to going in for you know direct or cross examination, I'm reviewing medical records, I'm reviewing the content of what's contained within those progress notes so that I can speak intelligently and effectively to what's contained within those. But I'm looking at them sometimes from a very different lens than maybe what somebody who is auditing for a prospective audit or retrospective, you know, pay or audit is looking at I'm looking at it from a fraud waste and abuse standpoint, typically. And what I would say to providers is that I believe as these ambient listening systems or these ambient recording systems become more prevalent. The likelihood of claims rising to a potential false claims act level is going to increase exponentially because providers should have known and providers have a responsibility to know what's contained within their documentation if they're relying on that to drive the level of service irrespective of whether it's an evaluation and management service if it's a procedure, what the diagnosis is providers are responsible in a kind of reminds me and this is the last thing I'll say about this. And you guys probably remember back to when providers, you know, in their transcribed notes, they used to say dictated but not read and that meant absolutely nothing. I don't know for whatever reason somebody told him if you just put that in there, it kind of see why a's. It doesn't it is the dumbest thing that I ever heard because there was not one case that I was ever brought into where a jury was like, oh, but it was okay because the provider said I only dictated it. I read it to make sure that everything was right. I'm sorry that this person died of an overdose of a drug that they weren't supposed to be on or at or a rate of a trip that they weren't supposed to be receiving. It doesn't happen that way. Terry Terry and Stephanie, let me come to y'all. Yeah, the one thing that drives me crazy about this and I had to kind of listen to what you were talking about to understand what was going on. So it to Scott's point is we have to keep pushing and pushing and pushing our providers that it is your note. It is your legal document. It is what the patients now are going to read because they have open access to their records in a lot of ways. And they can have them within 30 days. You got to give them to them. The biggest thing that it seems like I don't know the doctors or the providers and I say this loosely providers, it's not just MDDO. It's also, you know, mid levels and anyone that's, you know, treating the patient or interacting with them. One of the things that that's a problem and just in let's say, what is this. I see more and more patients coming in or an office visit and then an annual well or preventive is done after the fact. No, no, no, no, no. That doesn't even make sense. First of all, if it's a preventive, the CPT book AMA is clear. If an abnormality is found during a preventive or if there's a need for a full workup of an E&M, then you can have both. You can't have you can't say a patient sick and say, we're going to go ahead and do a well check. And then if you have a patient who again comes in for the annual well, which doesn't include an exam. So they say, well, we just the while you're here, you know, it's like while you're here, really am I getting a, you know, an oil change. So while you're here, we'll go ahead and do the annual well visit. And then you can tell they don't review it because the patient had a complaint and it wasn't addressed because they were already seen. That morning or you know 20 minutes before and and so it should be after the workflows are so messed up that way. But in just talking about this ambient thing, you know, Stephanie reminded me of when a patient, when the doctor's, when this first came out as far as using AI or starting it, it was a few years back as we all know. And they were using a type of Alexa type thing, you know, that can hear you in your house. And how many of us sit there and we're watching a show with our spouse, whatever. And all of a sudden, something said, somebody's name's Alexa and she responds and we're like, we weren't talking to you. Okay. And so, you know, and so it's kind of frightening because we had doctors doing that in their doctor's office and yelling because obviously has to pick up the sound. You know, I need to treat this. What's the, what is the appropriate drug? And I'm sitting, I'm sitting in an office auditing on site and I could hear what the Alexa response was and being a former nurse. I'm like, that's not the right mid. And I could see the doctor coming out and going, hey, I need to figure out this method because that wasn't the right response. And I knew that. But also the patients could hear it other rooms. And so I have a question to, and I guess Stephanie, you're next to weigh in on this. When this ambient thing is used, and I think Paul might have also mentioned it because of all the HIPAA implications here. What happens if it picks up something like, you know, they say 50% of, you know, office visits, there is usually somebody accompanying the patient, rarely does a patient go in by themselves. And so what if it picks up a conversation with the spouse or with a partner or a caregiver or a child or something that wasn't part of that visit, talked about a medical condition and didn't sign a waiver. So Stephanie, I'll say that to you because that's, there's all kinds of things going on there. - Well, and Terry, that's what I've been thinking about a lot is the compliance side because what everyone's talked about so far is pretty much we know that the physicians and HIPAA practitioners are not going to all go and read through their notes. So that's a given that whatever this thing spits out is probably what's going to go through. You know, I just met with a practitioner last week who told me and admitted that they carry the exact same note from the previous time forward. And because they don't have a lot of time built into their schedule, if it's the same, they don't add anything, they just sign it again and send it through. So obviously it came up on the audit, but you know, one of the things that stands out to me in this whole subject is when I've been working with and talking to different developers in this space, an interesting thing that I've heard a couple of times from them is that they build this, but their build includes no way of monitoring and adhering to compliance. It's pretty much like handing it over and saying, "Here you go." So to that point, Terry, you know, it's really important to make sure everyone, I think, is monitoring internally. And it's already hard enough when we talk about external audits for example, getting people to do that. But now something like AI is going to require it, I think a whole separate audit plan just to monitor what your system's doing. And you know, the other question would be, okay, if you have an ambient scribe, do you then have additional software that's being integrated to select the level of service and do the last part of that submission? And you know, I have a client right now who's implemented a lot of AI and other tech and I'll tell you that the brick wall we hit every single time is that it cannot critically think. So, you know, we know sources aren't always good that they pull in, we know providers aren't going to review it. We know that it doesn't have critical thinking. How's it going to apply that when our guidelines are so subjective? So there's a lot of moving parts here, but it really all points back to the fact that, you know, I'll say this actually. It's really irritating when we see all of these updates with companies outsourcing everything. Terry, I think it was you who told me that you had a client or a member, they're outsourcing entire revenue, the whole revenue team, the whole coding team, and they're all being told. I think Emory Healthcare is one of the recent ones to say that they're going to be doing this, but how is that possible when it can't critically think? So, you know, the whole thing, I just feel like we're living in a time period once again that we're going to see all kinds of investigations coming back after to things that we knew were going to happen. Well, as a compliance person, on a serious note, like I read this study, I think last week, and I tried to briefly find it, but I'll have to try and locate it. And it was some health system that was a bit larger, and I think they had estimated something like 12,000 position documentation hours would be saved through the use of like ambient scribing. And, you know, the point, the reason I bring that up is like under no circumstances that I can think of, will this not be expanding somewhat dramatically, right? Like I know, you know, as an auditor, when I talk to providers about documentation, usually I'm talking about bad stuff, for a lot of times I'm finding deficiencies, and one of the number one things that we all hear is like, well, I see patients all day, I've got hours of documentation, I have to try to work in at the end of the night, I can't figure out what the priority is. And so when you start to mention the fact that you can save, however many hours of position work time, right? That's like, when you take that big stake and you throw it like at the zoo, right? It's like, they are gonna come like running for that. And so I think we have to be cognizant of the fact that it is gonna expand, and that's gonna cause downstream implications. Like marketers are gonna get this information, whether they get it individually or in the aggregate, and they're gonna use it to market the patients. We've talked about what happened, so my other half works in the office, McThor, and senior living has the same conversations that I have when we're doing different things. And so I get treated to far more ads for senior living than the average person my age, right? And I don't think that's a coincidence. And you know, he may get a lot of ads for like healthcare compliance, I don't know, but there is going to be a marketing pickup for this. This data that's being collected is incredibly valuable on a monetization basis. - So I have one other question. I know we have to move on to the next topic, but since ENM codes are chosen by time or medical decision making, what does this do with the time factor? You're gonna have still doctors who love to timestamp everything the same time. Stephanie and I work on an audit practice together, and we're always face planting, everybody is 45 minutes or everybody is 30 minutes. There's never a variant. But if you have AI doing your work for you and choosing your level of service, even if it's not right, you can't use that time because you're not doing the work, right? I mean, that's how I would look at it. - Why would I, are you not doing the work? Because I mean. - They're saying they're paying for the work, so they should get to use time. I'm like, no, no, no, no. - That's a work, that's a work. - Yeah, that's a work. - But I think that's a great segue into the main topic for today, which is payers, downcoding, evaluation, and management services. So I wanna be very clear as I hope that I was in the post that I did this morning announcing the topic. As much as I think a lot of people would love for us to bash the insurance companies, this is not a bashing session. I think this is a session where cooler heads need to prevail. People need to be able to look objectively at both sides to understand what the when to where, the why and the how, and formulate a plan on how to address what's going on at the payer level right now. Now, keep in mind, what's transpiring right now is nothing new, okay? This type of behavior, and that's what I'm gonna call it. I'm gonna call it behavior. This type of behavior that we're seeing from the payers right now dates back to the early 2000s. We have had situations in the past where we have had various payers, whether it's the blues, and I think it's extremely important to keep in mind and to understand that when we talk about the blues, Blue Cross Blue Shield has multiple subsidiaries. They have subsidiaries in every single state just about, right? So it's not just Blue Cross Blue Shield as a single entity. It's the blues as Georgia, as Wisconsin, as Arizona, as Tennessee, as California. So very important to keep in mind. So last week, we started hearing again, the chatter that SIGNA was brazenly starting the process of downcoding the levels of evaluation and management service. Now, the thing to keep in mind, 'cause everybody started spouting off, this is illegal, this is illegal. No, it's not illegal. And I've been working on an article all weekend, And I was going to wait to see the conversation that we have today to kind of plug in some of the final details from what we talked about on the round table today. But it is not illegal if they stay within the parameters of the laws within their state for timely processing of claims, the fair processing of claims. And if they are doing it in conjunction with what is already in their provider agreements, their provider participation agreements. So there are two sides, well, there are three sides to every story. And I think my distinguished panel guests would agree with me. There is yours, there is mine, and somewhere in the middle lies the truth. So I want to stop there because I kind of want to take this on a whole trip around the sun if we can discussion on what is going on. So Stephanie, I want to start with you because I don't often start with you on things. So I want to start with you and get some of your thoughts on the downcoding of evaluation and management services. What you have personally experienced thus far and what you have been hearing from some of the clients that you are working with and then Terry will go to you and then Paul and then Scott and then we will try to round this thing out. So go ahead and take it away. All right. So one of the first things I think we need to acknowledge here is that yes, it's frustrating, but we also have to look at this and dissect this to why it's happening. And you know, from my perspective, I have a lot of, I could maybe even say anger towards the payers in this area. But if I also pause and think about conversations, I have every day, every week with my clients or potential clients. You know, we'll talk about things like, oh, I'm frustrated. I'm getting auto downcoded. Okay. Did you go in and look at that? No. Afterwards and appeal it. Well, no, I couldn't appeal it because it did support the four instead of the five. Okay. Well, when's the last time you've done an external audit? Well, we've never done one of those before. And you know, it's just this constant thing that's showing, okay, you're not even doing your own due diligence and monitoring internally. So now this is the result. And yes, I still don't like it. At the end of the day, I don't, I don't see how they're able to do it. And Sean, I know you were talking the legal side. But at the end of the day, everything I keep reading from the payer says, you must adhere to these guidelines. Do they have a crystal ball? Do they know that that document adhered to those guidelines or didn't? No, they're just making an assumption and then adding all the administrative burden back. It's like this back and forth poll where, yeah, I'm heavier on the frustration towards the payers, but the providers did it to themselves to some extent. We have a lot of bad actors who don't want to listen. You know, I'm working with a particular client right now and have practitioners that I'll reach out to and they're like, just close the note. I don't care what you're saying. I've been in the industry for 25 years. Close the note and bill it. And they don't even want to hear about it. So, you know, the industry on the provider side has caused this to happen. Yeah, one thing I'll say and then Terry, I want to come to you and get your thoughts on this. Folks, if you don't read your participation agreements and you simply sign on the blank line or what some like to call the dotted line, I don't know why they call it a dotted line because I've never seen a dotted line. It's always a straight line. Anyways, if you don't understand what's inside your participation agreements, your contracts with the payers and you start to chirp about this is unethical, this is illegal, this is not fair, what may be all of those things, but guess what? It's in the contract. They stated in the contract that they were going to do these things and you just have them to ignore it. I have providers that will reach out to me or their staff will reach out to me. Terry, we've had this conversation where they'll say, why can they do this to me? Well, can you send me a copy of your pay or agreement and let me kind of take a look at it. Let me analyze it for you. Why? I don't have one. What do you mean you don't have one? Well, I haven't had one for 10 years. What do you mean you haven't had one for 10 years? I mean, this is the bizarre stuff that I hear all the time and I say bizarre because you're in business. You're a business. Your job is to generate revenue as a business. Yes, our first concern is to provide high quality care for patients, but you're a business. You got to make money. Otherwise, you can't provide care for patients. So let me stop there, Terry, because I could just go on this rant forever. So one of the payers that actually just blatantly put something out and we can put out there because it's public knowledge is signal. So signal use health care put out something last week. And I actually forwarded to Sean go, did you see this? Because I was like, this is insane. And then send it to Stephanie and the panel because I was like, okay, wait, what? Basically, they're just saying arbitrarily they can down code. So I did some more research on it. And they use a formula, an algorithm type thing kind of like the CERT and they're looking for flatline coding positions that basically over 85% of their submissions are level fours or fives. And they're thinking, I guess on this is that that's not appropriate for every single patient. And unfortunately, some of the new guidelines make it a little bit tough, even for us auditors because we can have an acute illness on a patient that's pretty bad. It's probably not to the level of complicated, but it's an acute illness and then how they're treating it. And based on the new guidelines, it's still one thing. And so it's a level three. But then you can have two stable conditions and they basically refill prescriptions and talk about it as a level four, something like that. It drives me crazy because I'm just like, well, this seems easier, if you will, than what the level three was coded at. But one thing that Sean mentioned, you're signing contracts. So you may sign a contract that's two years, three years, whatever. But then what the payers do is they do policy updates and then those are not things you sign. Those are things that, for your convenience, they don't even send them to you. They put them on their website. And so you have to have somebody that's going on the website and saying, look what's new and who does that? And so I think that's the way I know it's kind of like you go into the L for trip advisor or some social media platform saying, I'm getting a lot of people saying bad things about my practice. How come I only have three stars and not realizing that? So you have to to keep up with these things and you have to have a point person. Maybe it's somebody in your compliance department. If you're a small practice, you know, I don't know, find somebody who was bored and needs to, you know, go on and find all these things to do. That's the only way I know how to put it because it's really searching it out, finding what their updates are. And a lot of the payers are doing this arbitrarily. It signals one of the ones that put, you know, they're, they're always seem to be the cowboys out there calling that because remember a couple years ago, they tried to do that thing with the 25 modifier saying that, you know, they weren't going to pay for any EMM. If you have a service on the same day and that got shot down. And now they're trying to do this arbitrary thing without reviewing records without requesting ADR. You know, so it's interesting that I realize you're not always signing your contract because a lot of you think those are yearly. I've seen doctors enter into payer contracts to three, four years at the same fee schedule or I need to do that. But I have seen that. And so just be aware that there are policy updates that you can argue that you can, you know, resist or fight against or now you may lose your contract. But it depends, you know, what you want to get out of that contract and is it even worth, you know, the time anymore. And also find out if it's within the policy because right now it's being fought through the AMA in California with the business and professions. So they say no, they say that is not an appropriate policy edition without doing it without making sure that you've got something behind it to support your position. You can't arbitrarily down code. And just like you can't arbitrarily up code either. Yeah. So something that I've been doing for the last couple of years on contracts and I've blogged about this in the past. And Terry, I actually, you and I, along with Jackie Colt, had a conversation about something else that came up with respect to 24/7, 365 access into the EMRs where I was able to, you know, come up with the counter argument to that and they backed off. But one of the things that I've been putting into contracts that my clients have come to me and said, hey, can you take a look at this? I've actually put a clause in there and we wait for the fully executed agreement where it says any substantive or material change to payment policy requires actual notification directly from the pay or to the provider practice and failure to do so. results in a potential breach and holding the payer accountable for any financial distress the practice receives. And I can't tell you, I don't know if they're not reading it and they're just signing it the same way, but you know we've had a couple of situations like prepayment reviews where they have literally put a practice onto a prepayment review that was a that was based on a substantive or material change to the payment policy that was not disclosed publicly and it was buried but per our provider agreement they had an obligation they had a contractual obligation to provide that to us. Now there are some good attorneys on the payer side that catch these things and they're like nice try there's no way we can do that because you're a small individual group but it doesn't matter if we can get these things in there it gives our attorneys the opportunity to be able to make a strong argument for the reason why what they're doing is wrong but let me pause there because Paul I want to throw this over to Paul for a second because there's something that I see where they say something in the the last contract I was right we're reading about this they were seeing something like and we have the right to add new services that are not limited to what's in the contract so you know and new policy guidelines that you're accepting and so a lot of times the doctors just don't have that kind of legal or compliant language should to fight it and so Paul I'll throw it to you because I know you have something to say on this whenever someone chooses an occupation you know whether it's doctor or whether it's what we do as compliance professionals you know it's hope that we receive a remuneration you know like one of the one of the greatest quotes about this was when the mom is in the pop is signed with you know Dunhill records and Lou Adler the owner of the record label said you know what's your goal here and John Phillips is like the goal is to have a steady stream of money from your office to my house and when physicians sign a contract that's really what they're hoping for they're hoping for a steady stream of income to a group of insured that goes from the insurance company to that physician practice based on the types of services that they are providing and the intensity of services that they are providing you know the RBRVS was really created in order to try to quantify this in the early 90s after 25 years of the Medicare program saying just report what you do on you know the first Medicare claim forms are out of a museum and you've got to see them to believe them it was basically right in narrative of what you did attach a price to it and send it in you know those days are over you know and if you're putting a signature on that contract and yes it is a solid white line we haven't had dotted lines for many many decades you have to make sure you know that you know again with every wish come consequences you know maybe you have a lot of insured lives that are underneath that insurance carrier but you have to understand everything that goes into that you know and thinking that Medicare and Medicaid are the only ones with regulations as to how they pay a claim in 2025 is an incredibly naive thought process. Scott let's let's talk about this because you know we have several clients that you and I work together on where one of our clients in Texas actually said to us they have more than 600 claims now that had been downcoded by the commercial pair and the impact that this is having operationally because keep in mind this is not just one issue right this is one of a collective of issues that practices are dealing with on a daily basis because even though it just may be sidenna in this situation that we're we've kind of brought up here but it could be united health care now is doing it in SIU on it or they can also be under a TPE on it from the Mac in the state or maybe the unified program integrity contractor for the Midwest has decided that they want to take a look at something this is just one other barrier to being able to provide comprehensive high quality care to patients because we're having to continuously drag providers into these conversations because we need them to create letters of medical necessity because maybe the person on the other end is not a clinical person who's reviewing the medical records and they don't understand how to deploy clinical judgment and as a result something that makes sense to a provider even though it may only be two or three sentences on a page which can mean pages of information to that provider to that person who's looking at it to their credit there are certified coder or maybe there are CPMA those two or three sentences only mean two or three sentences but this is a significant problem and this is impacting organizations abilities to function yeah I mean what bothers me about this is you know and I think Stephanie sort of said it best like this creates a new regulatory burden that is shifted like entirely to the provider because if your claim is being adjusted strictly based on whatever you populate on the 1500 like nobody's read any notes nobody's done anything then you as the provider have to decide and as we all know you know part of me as someone who's you know familiar with like gambling it's almost like a big right like the payer's gonna take like a little taste back and then you have to decide if you want to adjust it at the same time one of the things we talked about at the outset this isn't like a bashing the payer session it really is about getting the documentation right for the claim and making a decision about whether or not you want to appeal it so one of the things I think about sometimes and this was like 30 years ago it's before I ever worked in healthcare you know I was like 21 or 22 and I had moved to Florida and I had a primary provider that I went to see because I had gotten like allergies I think from the different things that grow down the air versus where I grew up so I don't go to the doctor a lot so now I end up like a year later and I have like a sebaceous cysts on like my ear and it gets infected my ears kind of blowing up so I go back to this doctor and he does whatever he's doing with the cyst and then you know I'm ready to leave and he's like how are the allergies and like how they're fine so then I get the thing you take to the counter right to check out and he's checked off that he did the allergies right and I'm like well you didn't really need to do that and so I think sometimes you know one of the things that makes me nervous as a compliance person is the provider's frustration with this whole process will boil up to the point that he or she will pitch their own solution and once you hear well you know what I'm going to do I'm usually like I don't think I want to know but they're going to tell me anyway and it's usually something like well I'll do the ENM service and then I'll have them come back tomorrow for the IND right and you're like oh no no no no and so I think like you know I think this is an arbitrary potentially unfair thing to do but I think as we've talked about you know one of the things that we should do as medical practices is make sure we are coding documenting billing in line with the intent of what these visits are about what the guidelines suggest we should be doing we should be cognizant of medical necessity you know it shouldn't be like well this person has diabetes but they're here today because you know they have a cold let me work up all the chronic conditions even though they were just here three weeks ago you know some sort of leveling because when you do that work on your end you're going to feel a lot better about your ability to push back or appeal some of these changes that may be being made without looking at your claim and you know to be fair to signal or whoever may do this like I don't know if they're using bell curves I don't know what data set they're necessarily using to decide to do this but I think just saying like well that sucks like yeah that's kind of suck but I think like you need to understand what your strategy is right and your strategy to me is like making sure that you feel good that the documentation that you're creating is going to stand up to these reviews understanding what the code sets are and being prepared to react or appeal these as is necessary I think the idea that you know they're doing this so I'm going to do something else that's potentially not aligned with good medical practice with the guidelines probably not a great solution but that's the way I think about it right and I you know what frustrates me like I said at the outset you know as long as I've been doing this work I sometimes feel like I'll run into providers who are just like I just want to see patients and document what I actually do and sometimes the guidelines will trip them up in some way because they're not creating like three extra pages of like john's sort of ride along with the note and you know that so I think once again this will penalize or land disproportionately on people who are just trying to do the right thing and I think that's a little frustrating. Well and I also have the conversations with my clients too. The same thing you just said, where the patient may have CAD, the patient may have diabetes, hypertension, but they already had that visit three weeks ago, and they're there today because they've got a bronchial infection, or they've got sinusitis, or something, and that's really what they're treating. They basically say, "We just gave them Celestone or just an injection today," and that's really a level three because it's DRN. You don't have to come back. I'll solve down code. They could try to code to a level four. They see how, but they have chronic conditions, unlike what they didn't address them today, just because they have them. Does it mean they get credit again for having addressed them because it wasn't even needed to be addressed? The other thing that I see a lot is, and actually recently, is I'll see providers that will do this whole node and have a level three or four with a 25 modifier. I'm like, "What did they do that day? I'm looking for it." And all of a sudden, I'll see that they did an injection, but nothing in that ENM said they needed an injection, wanted an injection, talked about an injection, recommended injection, or ordered an injection. So I see no reason for the injection, but it was done. I even have providers say, "Well, you should assume that's what I was going to do for that diagnosis." After my head explodes, I'm just like, "No, we don't assume in the helmet here. You have to show us your thought process that you got from here to here, and why?" I said, "It's all about risk. It's all about what you do, not what I'm assuming you're thinking you want to do." And it's amazing to me that I even get doctors that still or providers that still don't understand the one thing they put in in CPT that just listing a diagnosis. If you're not somebody that's following it or addressing it and it's not something you're doing with, you don't get credit for it. But it seems like they want the HCC, the hierarchy code. They want credit for this higher weighted, I guess you'd call it, diagnosis. When that's not something that's even in their specialty. Well, in the language of the CCI, at least as far as Medicare goes, states that the decision to perform a minor procedure independent of any other treatment options or things of that nature is bundled into that procedure. So what I run into, and this is another one of these things. I can't say this definitively, but to me, it's like this artificial documentation that gets created around some of these knee injections. Where the patient was here four months ago. They had an injection. Now the injection is wearing off. They want another injection. And that's the history. Then you get through the note. And it's like, "Well, I discussed different treatment options with patient, physical therapy, the possibility of surgery, and after joint decision making, we decided on an injection." And I'm just kind of like, "Well, how about that?" You know? Once again, we have made the same decision. And when you're going down that path, then you're not advancing the patient's condition. Right? Now, if the provider tells me, I got a conversation with the patient that this is like their seventh injection and the efficacy is wearing off. And at some point in the next six months, they're going to need to have their knee replaced. That's a bit of a different conversation than just we talked about all these treatment options. The same way we talked about them four months ago. And we just decided to do the same thing. But I'm going to bill a 9-9-2-1-4 for that because I mentioned major surgery. And those are the kind of things when you want to think about why a policy like this comes out. You know, as someone of a certain age, and I know Paul will remember this, and maybe some other people. But if you ever read Mad Magazine, and five verses five, it was just these increasingly exotic schemes they had to come up with to try to like take the other person like down a peg. And that's where we get to sometimes. Well, and I also see the urgent care is terrible about this. They said they get a lot of complaints from patients when they come in for the flu or a cold. And if they're not given a script for an antibiotic, they get really mad. And then they go and leave some kind of Facebook posts that this is a terrible provider. So what they do is they write a miscript if needed. And they write a miscript for this. But then they want the level four saying because they wrote a miscript for an antibiotic that they may or may not need, that's prescription drug management because they they talk to them about they don't need it. And I'm just like, well, most of those I can't even get the presenting problem to a level. I know. I know. And so I'm just like, no, it doesn't work that way. And Stephanie and I were dealing with a group last week, that's their pediatric group said that every patient, you know, that's a minor that comes in with a slight fever is automatically level four. I'm like, you guys have to say, you know, and talk to our listeners, you have to stay away from anything is automatically anything. Independent historian. Same thing, right? I'm like, this is 16. Why does or how how do you document it that way? Yeah, how do you document it? Yeah, well, that's one thing that we get a lot too and actually shone all of this because of his work. But we get, well, how do I get to a level five? What do I need to document to, you know, to make sure that this is a level five? And I'm just like, and I'm out. So, you know, let's talk about do you squeeze the toothpaste from the bottom or do you just roll it up and, you know, squeeze from the middle? So I just try to change the subject. Sometimes I want to say when they ask me, how do I get into a level five? I'm like, well, put a baseball bat behind the door in your office, hit the patient like eight times. Now when they need to go to a hospital, that's a level five, right? It's like, you know, make the person shicker, right? Like people are what they are. I saw some little methods. I'm feeling when I screw on the way to what was it? Hospital in the low column. So let's see if a patient that needs infusion therapy, but because they have home health and they couldn't get it. So then home health basically says you got to go to the doctor's office if you can get it. And you know what? We'll send you over to the infusion suite at outpatient hospital and we'll make sure that you can get that today. That's low level. That is not high level. It's just transferring things. Sorry, I didn't meet an eruption. I have seen that seem the same trend in urgent care. I will say that some of the urgent care notes that I've been seeing even though they transfer the patient to the ER, they're smart enough to know that it's not because the patient has an imminent health crisis. It's just they've reached the point either in the imaging, in the testing or the care that they can provide in an urgent care setting that they need to accelerate the care. And you know, and that's still a four. That's not a five. I mean, it's a five when that person is wheeled out of the urgent care center into an ambulance and taken. Yeah, because sometimes it's sometimes it's just if you want it, you have to go to the hospital. That's I mean, we don't do this here. So you can either go make an appointment with your doctor or you can go to the hospital. Well, I think, you know, in wrapping this conversation up, there's a few things that I'd like to put out. There's some takeaways for the audience, right? Because again, as highly problematic as this behavior is and as much as everybody wants to point the fingers at the insurance companies, which they deserve a lot of the finger pointing, right? Providers also have to turn that finger around and point it at themselves, right? So for me, I think there's a few things that I'd like for people to take away from this discussion and anything that you all think that I omit, please let me know. I think the first thing is you've got to track your downcoded claims. You've got to submit appeals with full documentation and request removal from auto downcoded lists. This is something that I just did for one of Paul's and my big clients in the state of Texas with United Health Care and they removed them from this list. It is done. It came straight back from counsel that they were removed. Providers have to ensure that they're adequately documenting the medical decision making and if they're relying on time, that it is clearly supported to not only prevent the artificial downcoding on the front end, but to support and uphold the proper level of service on appeal. Third, you have to conduct ongoing coding on it. It's to Stephanie's point earlier. You've got to identify patterns of unethical or potentially illegal behavior by the providers for negotiations on contract renewal, but it's up to you as the provider to make certain that you are conducting bonafide audits on a regular basis and it's not, hey, let's just pull 10 charts once a year and see what that tells us. You've got to do a random sample. You've got to do something that rises to a proportionate level of the claims you're submitting. And to me, I think 10% is an accurate depiction of where you need to be. And if you don't want to go that high, at least follow the guidance of the office of the inspector general, at least pull 100 encounters. 100 encounters gets us to where you need to be. Excuse me. To the point that I made earlier, you have got to read and understand the terms and conditions of your payer contracts. And if you don't spend the money to have them analyzed by either a competent attorney or regular pluric compliance person, then have somebody internally within your organization that knows what they're looking at and how to negotiate these things. And finally, if these things pop up, join the available class action suits or file formal complaints to the state regulators if you believe patterns suggest either unfair practices by the payers or unethical behavior. You can't just sit back and complain. That's my point. You've got to take active steps to engaging to get these payers to retract some of these abusive, over-aggressive, over-reaching, potentially unethical and potentially illegal activities that they're rolling out. And the only way to do that is to push back is to use your voice and to fight. All right, let me give everybody one last word. Paul, start with you. Pardon my computer issues. Well, again, it's the importance of understanding what you're agreeing to at the very beginning of the contracting process. And I see more and more practices who are kind of farming this out to people who they believe are more qualified. Well, they may be qualified on the monetary end, but they may not be qualified on the medical delivery end and what that looks like. There needs to be a combination of those people whenever you put pen to paper. Stuff in the hour. Yeah, so in regards to that ambient scribing, I would just suggest that everyone goes in and looks around your system or starts to ask questions. I've actually had clients that use long-term systems out there that we're all familiar with, and they've been integrating these products in. They're not even always having to buy them separately. So make sure that you know from the compliance perspective what it is that's already been implemented into your system. Miss Terry Fletcher. For those of you that start seeing any of arbitrary down codes for your ENM services, make sure that you've reviewed them before you try to fight them. So make sure that they are, they weren't correct in downcoding them. You might want to do a proactive external audit just to make sure you know what's going on before it comes. And finally, not least, my buddy Scott Frost. Thank you. I was just going to I'll take you back on what Terry said and just say that like if you're reviewing these arbitrary downcodes and you find yourself agreeing with the downcode, like the answer is not, well, we'll just keep doing what we're doing and they'll just catch some of these where they catch them. The answer is probably not, let's add stuff to the documentation that we didn't necessarily need to do. You know, you want to make sure that you are providing appropriate provider education because you know, if you are losing these appeals, that's not very productive for you time wise. You know, and if you're making no changes and you're just expecting to sort of keep sliding through and maybe they'll take some back, you may find yourself with a bigger problem sooner than later. All right, that's going to wrap it up for this episode of the Compliance Guy, our Monday roundtable. Thank you to Paul, Stephanie, Scott and Terry, Christine. We'll see you in a couple of weeks. Thank you to each and every single one of you who tuned in, logged on and hung out with us for just a little while today. We'll be back in two weeks with a brand new podcast from the Roundtable panel. So until then, remember, be good to yourself and more importantly, y'all be good to each other. Take care.