Ethical billing and coding for chiropractors: Medicare, exercise and fees

but also the chiro doesn't have to do it. You can have a staff person under your supervision and training to make sure the patient is doing the exercises safely, make sure they're doing it properly, have the proper cues. They pay well. And I make a big emphasis. I'm not as big a fan of having patients do exercise at home. Not to say I don't want them doing it at home. Don't get me wrong. But if I tell a patient to go home and do X, Y, and Z, and I'm expecting that they're doing it, the next time they come in, they're not any better because they probably didn't do it. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now your host, Dr. Sebastian Gonzales. Hey guys, it's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time and you're a patient or lay public. I apologize. This is going to be one you want to go dark on as well as last week's. This is going to be very helpful though for clinicians. And if you have not heard last week already, we had Sam Collins from hjrosscompany.com on. I've been to his ethical billing and insurance-based workshop or seminar. Very helpful. And the reason why I wanted to have him on this and last week, and he had so much great information that I had to put this podcast in it too, is mainly because if you're a good clinician and you have no one to treat because everybody's saying, hey, I only want to use what's in my network, you won't see anybody and you can't help anybody. And so I'm not saying that I'm going to go in-network and use a bunch of insurances by having Sam on. But as you'll hear with the podcast, Sam's pretty darn convincing about how to use these to meet people where they're at and also to make sure that we grow as a business so we can help more people. And so my personal thought with this so far is that you've already heard part one. You might be wondering, is Sebastian going to change everything he's doing? I'm not going to change. I'm not going to change what I'm doing. My recommendations of care still are based upon what the patient needs and what their goals are. And so sometimes using insurance to kind of meet them where they're at a little bit, it just sometimes it takes a little bit longer. Sometimes they have to pay a little bit extra out of pocket. But either way, you just have to be a little bit more creative about navigation of where we're going to insert certain types of care with these people. So that's the way I'm kind of considering listening to Sam with this stuff. Because I don't want a high-volume practice personally. But some of you guys might. And so use the information as you will. So if this is your first time in the podcast, again, just listen through some of the archives. The archives are great.

Like I have case studies in there. I have interviews with some of the industry experts. I have some personal stuff that I put in there. I think they're original ideas. I'm not quite sure. But go into the archives. I think you'll really love the stuff back there. Again, if you're a lay public, I apologize. You want to go dark on this one. But we as we believe that if we're providers who are trying to be help, we're trying to help a lot of people, then we need to figure out how to give them the door too. And so it's not always the referral. Sometimes there's other barriers in the way. So we're going to have on Sam again. And first, I'm going to go into a personal story. So you guys really understand who I am as your host. Hopefully, if you guys like your host, you're going to know and love me and want to follow me on this journey. So I try to share little tidbits about myself and stories about what happened to me. So hopefully, you get to know me a little bit better. Then we're going to get riding into the interview with Sam Collins. So I recently had a, I don't want to say younger patient in the office, but they're about 18 or so. And so I was having her push a sled.

And so I said, you know what? Here's what we do. We do that, that, and that. And it's going to be it's going to be money. And she's like, what? I said, yeah, it's going to be like money. Like, it's going to be good. And she's like, oh, like the good, good. I said, oh, is that, you know, the good, good. She's like, yeah, the good, good. And I said, okay. And she's like money. What's that mean? So we kind of went down this, this thing of like, what are some, what are some age related things you would say like rad or, you know, what came out of your era? And so I was like, what, what comes in your, I want to be hip right now. Like, can you give me some stuff that you actually say? And she's like, so you'd like, how about this? Like, so what if someone fell?

Like they would just like walk in and kind of trip on something and fall and they weren't really hurt. And she's like, so what we'd probably say is sometimes life be like that. And I'm like, okay. And another one, which she said, I couldn't remember this one for life, but I'm starting using these in my Instagram posts. I think, oh, sometimes it'd be like that, you know, sometimes life be like that. The other one is like, it hits different. And I was like, how do I use that? And she's like, oh, so right now I'm pushing the sled. It's a little different than squats. It hits different. The sled hits different. I'm like, okay, I'm going to start using that. So anyways, if you guys have some cool, not cool terms that you like your kids use, I want to, I want to be super hip relevant to the era. So give them to me. Now let's get in the show.

You know, going back to all good advice, by the way, I think I did, I did mention, I'm going to mention in the, in the followup to this, to this interview that everybody should go to your courses and it was hjrosscompany.com, right? Yeah. hjrosscompany.com. We have all our, we have them listed. We have actually listed this year all the way through September. Our courses are eight hours of continued education, but here's what I'll tell you. In fact, it was something I was very happy for this. Most people that come, they always come back. We get a lot of return customers, but I think, and you've been, it's the only seminar I think that deals with true business and of chiropractic.

And I think that's where a lot of people miss out on seminars. Like I had someone that went to an ART seminar and I think ART is great. I'm not putting that. I'm just saying he goes, you know what? It was great, but it was really expensive. He goes, come into your seminars. The only one that actually made me money. Right. There's a thing to do and look at this as a business. This is why for California, by example, the course that we teach is a mandatory hour course because it's ethical billing and coding, not cheating, ethical, but you've got to think of how do I run the, like by example, I think most of just, just a simple thing of how do I set my fees? Most people aren't familiar with what's called the relative value unit. So they've got fees all over the place. They're charging one fee way too little or way too high and ruining their business model. It's another to go in and say, what code combinations can be built with. None of it is very hard, but if you think of it in school, you learn none of that. Cause where'd you go to school, Doc? Uh, SCU. Okay. SCU. So now when'd you graduate? 2008. Okay. 2008. So I'm pretty sure. And I mean, I have no idea. I'm just asking you, did I come and lecture to your class at some point before you graduated? Yeah, you came, I think it was about an hour. I want to say it was in the upper terms around like six, seven, the problem. And it's good, but truthfully, a lot of times when I come to the schools and I go to most, I go to Palmer and SCU, I go to life, I go to Parker, but right before you're like, Oh, I don't care. You know, cause you're focused on the boards. And then you realize later you're like, shoot, that packet he gave me is the thing. And I say that I go, this packet is what you're going to do for business for the next three years, the diagnosis. But most of us forget that. Cause we have this dream of how am I going to go out and practice? Cause I think we've all done this. You're in school and you're thinking, okay, if I see 15 people a day and they all pay me $50, I'm going to make seven 50 a day. I do that times a five day or a six day week. And all of a sudden I'm making, you know, somewhere around 15 to 20,000 a month. I'm going to start off making 200,000 a year, which would be great. The problem is you get out in the real world and you're going to have five people that are paying that. Now, if you market yourself well, and I'm not saying you can't get more, you're infinitely going to find more because you have to remember 90% of our population has health insurance. So therefore the biggest market of patients is going to be through insurance. It just, you have to muddle through which ones are good or bad for you. And that could vary depending on your location.

Yeah. So I can talk about ILW all I want, but if you're not in the South Bay, who gives a rip? Yeah. You know what? I know for just my, my own personal experiences that with, um, or one of the barriers that I've had with accepting insurance, let's just say, let's just say ASH just for an example, is that if they only pay for an adjustment and I like the, like you kind of mentioned, like, here's how I want to practice. Like, cause everybody has their dream of how they want to practice, how they believe care should happen and so on. And like, so I, I really enjoy, adding corrective exercise and like almost everybody deadlifts or squats in here, but those aren't covered services. And so I kind of consider like with, let's just say someone comes in for that 99 cent store in target. How do I upsell them to the thing that I really want them to do in addition to doing it in a way that works within the insurance, um, program?

Well, so you bring up a good example. ASH is not a bad company, but they very well limit a lot of chiropractic. A standard ASH patient has a per diem. In other words, everything you do is included. So when you say they don't pay for exercise, yes, they do. It's just included in the $26. So that's where you go, well, they don't cover it. Well, they do. It's like, do they cover ultrasound? Yeah. If you do ultras, if you do 10 therapies on an ASH patient, plus an adjustment is $26. If you do one adjustment, it's still $26. So it's an inclusive, it's per diem. So I'm with you. Patients need active care. If you look at any type of recent, uh, protocols for care, in fact, I just did something on a personal injury seminar with Sean Steele. So I did a lot of research on whiplash associated disorders, WAD. And it's interesting. The number one thing you should do beyond manipulation. Now, the thing I will say that I'm really excited about almost everything that's dealing with neck and back problems all indicates manipulation, meaning chiropractic.

So that's a real positive, but the other thing they highlight is active care. Now, when I say active, I literally mean exercise. So this new protocol says patients should begin actively doing things, at least in the shoulder blades or the posterior chain, as soon as the pain permits, not a lot of massage and otherwise. So by example, let's say we have a, a regular blue shield of California policy, a regular blue shield of California policy, for instance, will pay up to five services per visit. Now don't get too excited. The fifth service is paid at 10%. So that's kind of a throwaway. If it's worth a hundred dollars, you get 10, but the first service is paid at a hundred percent.

The second service is paid at 80 and then the next two at 40. So by example, the adjustment code 98940, the allowed rate for that is about $34. For therapies such as exercise, 97110, the allowed rate for that actually is slightly higher than the adjustment about 36. So don't get too good. So in other words, if I'm billing out three to four services, let's say an adjustment plus two units of exercise, that's close to 80, maybe a hundred dollars for that visit for that blue shield of California, not, not cover California. So in that instance, yes, that would be covered. So if I'm doing an ASH, the exercise is covered, but it's included in the per diem, but a non-ASH policy would pay for exercise. Exercise actually has a very high value. I think more offices should focus on that and not massage.

I'm not against massage, but let me understand why I have a slight bias. I'm 59 years old. I've been around a long time. Massage in my dad's practice had no place at all. He didn't do massage at all. If anything, he put you on that roller table and it never was charged for just what he did at the end of the visit. In the 1980s, the chiropractors, in my opinion, overly embraced massage. And I'm not saying they were wrong in doing so. If there's a policy someone has that covers massage and they pay well for it and the patient wants it, why would I not give it to them? They're not giving me an issue. Well, that has changed a lot. As you probably are aware, massage is not payable when it's done in the same region as manipulation. Same with manual therapy.

Part of that reason is our profession overly embraced it. It became what we did. So in other words, we did so much massage, they consider massage part of what we do because literally 98% of patients that came to a chiropractic office always got massage. Therefore, it's part of the service. So we kind of stepped on the golden goose. Well, the other side of that is massage as a consequence is not well paid. So if you have a practice doing massage, you're going to fight tooth and nail, almost never get it paid unless you do a separate day. So it's a hassle. Here's the difference. If you do exercise, it doesn't require a separate area. The problem is we've taught our patients. Coming in our office is like a spa. Coming in our office should be actively rehabilitating. If you think of a physical therapy facility now, I doubt if you went in there, you would see any massage going on because they have the same issue. They don't pay for them either. But when you go to a physical therapy facility, what do you see? You see a gym essentially because they've realized that exercise is the thing that really gets a person better. Now, I mean, if massage worked, heck, chiropractic wouldn't exist because massage has been around a lot longer than we have. But it's the manipulation that really makes the difference. So as a consequence, what I would focus in on is doing exercise. Now, does that change for ASH? No, they're still not covering it. It's considered inclusive. However, when you're talking non-ASH style policies, do they cover it? Yeah, they do and do well. I would just say, be careful. No one needs an hour of exercise. But I say one to two units is reasonable. So let's say someone comes in, they get an adjustment. Let's just say your normal fee for that is $45. I'm making that low. Your fee for exercise is 50. Exercise actually has a little higher value. So the actual build amount is $145. Now, let's just start with, isn't $145 a lot of money? That is. I mean, you know, that's a lot regardless of, you know, that some offices charge even more than that.

Imagine someone that charges $60 for an adjustment and $65 for exercise. That's a $200 visit. I mean, I look at that and I go, come on, who's going to pay that? But at $150, so if I'm billing the $145 to insurance, you can assure probably you're going to get in a contracted policy payment of about $80, which means you're writing off the rest. But who wouldn't mind an $80 visit? I'll take an $80 visit all day long. Person comes in, I adjust them. I have a staff person following the exercise. And I make a big emphasis for exercise because that's what gets people better. But also, the chiro doesn't have to do it. You can have a staff person under your supervision and training to make sure the patient is doing the exercises safely, make sure they're doing it properly, have the proper cues. They pay well. And I make a big emphasis. I'm not as big a fan of having patients do exercise at home. Not to say I don't want them doing it at home. Don't get me wrong. But if I tell a patient to go home and do X, Y, and Z, and I'm expecting that they're doing it, the next time they come in, they're not any better because they probably didn't do it.

Right. In truth, if someone has knee rehab after ACL, could they not do that at home? Could you give them a few sandbags, show them how to do lunges? Why is it, though, that we put them through a six-week course of directed exercise to make sure they're doing it? Right. So I would tell an office, don't be afraid to actively rehab a patient. Give them anywhere from two to four weeks of care. I don't think you have much problem. The key is volume. What we have to do in chiropractic, and I'll see if you're probably familiar with this joke, how many chiros does it take to change a light bulb? Yeah, yeah. The answer is it's one, but it takes 30 visits. That joke is slightly funny because that's sort of what we do. And I'm not saying there's anything wrong with that model, but that's not insurance. What I think we need to understand is to get our patients, we need to treat everyone eight times. What if there was a thing where everyone that had back pain must first go to a chiro for five visits before they went anywhere else? Can you imagine the volume of people we would see? Oh, yeah. But more importantly, how many patients with back pain in five visits would you not probably get them pretty much back to resolution? Now, I'm not saying, oh, I'm perfect, but I mean, getting to pre-injury status.

I, as an Olympic athlete, I hurt my back in 1995 or four pretty badly where I was doing a squat. I think I, I thought I bulged a disc. I was like, oh my God. Anyway, I can remember getting adjusted and I thought my career was over because I thought this is it, you know, that's, it was so bad. And the thing that was remarkable to me was after the adjustment, how much better I felt. And I say this is I'm a child of a chiropractor. Unless you're really hurting, you don't understand the value of an adjustment as much. Cause if you just get a tune up adjustment, it feels good. But until you go, wow, I went from a pain level of 90% to 30% in literally a minute. And I remember distinctly a week after doing that, I was back running and doing everything I could. And I was really surprised. Now, clearly I didn't bulge a disc, but what I'm getting to is, did it take 30 visits for that to happen?

It took about four adjustments. And so we've got to set ourselves up that we need to treat everybody, get everybody understanding care. Cause once a person's been to a chiro, I think they understand the value, which means I start everyone with insurance cause that's where they're going to start. But I'm going to say, Hey, look, your insurance says health insurance, but is it really? No, it's sick insurance. So here's the thing I can adjust you and get you back to some state, but what are we going to do to keep this functioning? Now, not everyone's going to buy into that, but what most people go, you know what? There's a value here. If I don't get rigged, I go to the gym every day. If I'm not getting adjusted, I'm going to have problems because I overstress my body and there's a value to me. Now my insurance does cover, but nonetheless, what I still pay and understand that's the market that we also want to tap into for people who understand that because you can't tell a person, Hey, look, eat fruit and vegetables one day and you're good for the rest of your life.

No, you got to do it regularly. So that's why good chiropractic care needs to be regular. And that's what I think cash offices often do. They get people to understand the value. So you're getting this, that's the back into the, the diversification you're talking about. So they might come in with an insurance, but then that's sick insurance. And then you would propose the other part. Yeah. So let's say you're not going to convert everyone. Trust me. They're going to people go, no, like right now, this time of year we're before Christmas, not happening. People are like, no, no, black Friday. I don't want to put, you know, when they're really hurting, they'll come in, but they're, they're not all of a sudden you notice things dry up. That's why prepay pens work good this time of year because people can keep coming or if they have a health savings. That being said though, generally what you want to try to do is talk to each patient about it and you're not going to get everyone to buy it. But what if you get a third? What if you get 20% that's a lifetime patient and what you'll start to notice, you'll get more and more of the, you will perpetuate what you put out.

If you're willing to stick by a cash practice, stick to it and say, nope, I only take cash. You'll eventually either die or thrive because you're either going to get people that understand it and want to come in or not. And so if they're not coming in, you're not doing it right because some people do it there. You're not doing it right with your demographic maybe, but you have to realize there's a place for it. You just have to stick with it. If you had a policy in Medicare, by example, you can join Medicare and be a par or non-par doctor. And the difference is a non-par doctor still belongs to Medicare, but they can collect up front. And I have a couple of offices. They're non-par. When every patient comes to them for Medicare, every patient knows they have to pay up front. So they have, if a Medicare patient comes and doesn't want to pay up front, they don't see them.

They don't worry about it anymore because they have so many patients that come that want this. In other words, they're the same referral that I get. When someone refers to a non-par doctor, they're going to tell their friends, Hey, my doctor is great. He takes Medicare, but it requires you to pay up front and then you get the check from Medicare two to four weeks later. Yeah. You build that by patients understanding and giving them the correct expectations. You know, I, I, so I did an email you, um, what we were talking, emailing a little bit about Medicare and Oh, actually I should ask you, do you have to go in a really quickly or no? No, we can say for a few more minutes. Sure. I mean, it's, you know, it is an easy day for me. Okay. I only have two more questions in it. You brought up the Medicare one. So I guess I'll address it now is that, um, with Medicare, like I know I personally, I've some, some people who, who come in with and they have, they have great insurance right now and they're about 62, 63, you know? And so like, I kind of talked to him a little bit about, I'm like, are you, what, I don't know what's going to happen when you get to Medicare because I am not in Medicare non-par or par, you know?

And so I wanted to have that conversation with them now because I don't want to lose these patients. They trust me. They like me. They have a good response here. And so that's why I was emailing you a little bit about Medicare. I'm like, what are our options here? Cause I, I want their policy to help them on the other end. It'll probably still be around, but also at the same time, it's like, if I can't get through Medicare as a barrier, then I won't be able to work with them. Does that sound right? Yeah. Well, here's what you have to think of. I, and I, and again, I just, I look at everything. My mom was a brilliant business person or a brilliant investor because my mom always looked at numbers. One of my mom's best investments was pick and save, which is now called something different. I can't remember, but it's one of the big lots.

Big lots. Yes. Her, my parents' financial advisor completely was like, no way, Nell, you shouldn't do this. And now I was about 15 years old and my mom was adamant. She says, no, I want to buy it. And the guy was still. And so anyway, she bought it. And this single thing is what made this guy a superstar above. He worked for Lehman brothers or somebody at the time anyway. And here's why my mom bought big lots. She goes, I've been to that store and it was relatively new month at the time. And she goes, it's really busy. It was the 99 cent store before. Now to give an example, that stock quadrupled and split multiple times. So my parents made, I don't want to give numbers, but a lot of money off of that. And so I look at the same way for us as a business numbers.

And I bring this up for Medicare. I'm a baby boomer. I was born in 1960, probably your parents too. So realize anyone born after World War II, basically 1946, whatever, up to about 1965 are what we call the baby boomer generation. And there's a lot of us. That's 10,000 people a day for the next 17 to 18 years that become Medicare every single day. So statistically, I want to say the dates like 2030, that's going to be the first time in the history of the United States, there are going to be more people over the age of 65 than under the age of 18, which means the bulk of patients are going to begin to shift to these older people. So now this brings me back to your question specifically.

When someone turns Medicare age, they get Medicare, whether you want it or not. Now you automatically get the hospital portion. You have to purchase what's called part B for the chiropractic or doctor visits. Almost everyone does because it only costs a little over a hundred dollars a month and it comes directly from your social security. It goes to the doctor. So everyone gets it. For chiropractic, the average Medicare patient probably has seen 20 visits per year. And the reason why 20 is they're older. They've got spinal degeneration. Now I will qualify to say Medicare only pays about $40 per visit on average. But if you just do these numbers, so if I take 20 times 40, that means that's $800 a year per Medicare patient that your office would receive. Now that's just talking manipulation.

There could be payments from the patient for others. Let's just leave it at manipulation. If I were to have a thousand Medicare patients, that's an $800 a year practice. Now understand that's a lot of visits. I'll say that's probably, but it's an area that I think sometimes people lose sight of because it's mandatory insurance. I don't like Medicare for all, except if they did this, if they made Medicare available to you, like I'd ask you what you pay for insurance now, I don't know, but how would you like to have a policy that would cost you $600 a month, that would have $180 deductible, would include hospital and doctor's visits. Would that be a viable insurance to you?

I think not me at this age, but for you paying two grand, I think so. Exactly. But my point is, so for someone, when you hit your 50s, insurance goes up. You're right. So what I would love to see is that if someone wanted to buy Medicare, let them buy it. You know what I'd love about young people buying Medicare? They wouldn't use it, so it would help. That's how insurance works. Life insurance works because enough young people buy it, so by the time an old person dies, either their policy expired or they didn't need it, but it's meant for insurance if something happened young. So I bring this up for Medicare to say this.

Why would I turn these patients away if I learned to make it work efficiently? So now let's deal with what you said specifically. In order for a chiropractor to actually treat a Medicare patient, you have to register for Medicare. You technically cannot treat a Medicare patient for cash without being registered for Medicare. So if you decide to say, hey, look, I don't want to register for Medicare. That's your right to do so. But when a Medicare patient comes into your office, you literally have to turn them away because under federal rule, you have to bill Medicare and only providers who register can bill. And so confusion comes in because you're going to hear this term called opt out.

And that's a specific term only for medical doctors. Medical doctors can opt out, but chiropractors cannot. So as a consequence, people think, well, I'm going to opt out. No, you can't. You have to register for Medicare as par or non-par. And here's where I think most people make a mistake. I would register for Medicare. And the reason I would, your name goes in the book. People can find you. And let's face it. Ask your parents, do they expect to use their Medicare? You're darn right they do. They're not going, I worked all those years and I'm not going to use it. That's the one thing everyone that gets older says, I finally get to use my Medicare. And Denny's discounts at four o'clock. So here's what I do. I register and become non-par. What a non-par provider for Medicare means is that the patients pay me up front. I don't accept the assignment. Now you're familiar what I mean by don't accept the assignment. It goes to the patient. It goes to the patient. So in other words, patient comes in, they pay me the $40 or 45. I submit the bill to Medicare and then Medicare pays them the 80%.

So in other words, I can still kind of be a cash office, but here's what I'll ask you, Doc. If I came to you, what is the cheapest price I can get for a cash visit right now for you? If I came and said, Hey, look, you know, I want an adjustment. What would my price be? $75. Okay, $75. So now for a Medicare patient, for an adjustment, you're not going to get $75. You're going to get $40, $45. So now you have to determine, can I accept that? Now, when I come to you and pay $75, do I get anything else for that $75 or is it just the adjustment? That one's just an adjustment. Okay. So now we have to look and go, okay, I'm going to get one third less for a Medicare patient.

Now you may say, Hey, look, I'm so busy. I don't need it. But I look at it from this standpoint. If I could see 10 to 15 Medicare patients a day for an adjustment at $45, would it be worth it? For me, it was because it's just numbers. I also find Medicare patients to be great. referral sources. Medicare patients love you because you're the only doctor that truly gives them help. You know, you adjust the joint. If you're giving medication doesn't help joints as much as people would like it to. Adjust to get them moving. And Medicare patients are changing. You look at Medicare patients now, they don't look like Medicare patients of 40 years ago.

Right. So I would suggest, again, register as non-par. Patients come in, you treat them, you submit the claim and don't go crazy. Once you hit 12 to 20 visits, you then say, okay, Medicare is not going to pay for more. Unless they have a very severe diagnosis. Keep your limited 12 or 20 visits. After 20 visits, the patient can go what's called an advanced beneficiary notice. In other words, what Medicare says is once Medicare is not going to pay or consider it maintenance, you then put the patient on a cash visit. Now, when you put them on a cash visit, you're no longer required to do the Medicare rate. So while it's covered by Medicare, you're limited to 45. But when they go off of Medicare for maintenance, you could charge your 75. Now, I'm not sure that works because the patient can go, wait a minute, when Medicare paid, it was 45. Now it's 75. But what if I maintain that patient? So I would look at it as just numbers. Now, if you're saying, hey, look, Sam, I am busy as all get out. Why would I replay? If you're getting, let's say you have a capacity to see 20 visits a day and you have 18 patients every day, you got room for two. I would first look to how would I fill those other two with $75 patients? You know, how do I market to that?

But let's say you can see 40 patients a day and you're seeing 18. Would I not want to accept 10 extra Medicare's a day? Because that means an additional $2,000 a week. That to me would be worth it. Medicare is pretty straightforward, too. People make Medicare too hard. Medicare has a very specific protocol of billing. Once you learn it, it's not hard. It's just different from what we've done. That's why we do seminars for it. That being said, though, you have to register for Medicare to treat them. So if you're not registered, you have to turn them away. Now, let me back up, though, and say, hold on. That's not 100% true. And I want to be careful. Everyone listening, please take to what I'm saying specifically. I am not recommending this per se, but there is something in Medicare law that would technically allow you to treat a Medicare patient without being part of Medicare. But it's very specific.

A patient always has a right to not use their insurance. So a Medicare patient, too, under Medicare rule has a right to say, I don't want to use my Medicare benefits. I don't want you to bill it. I don't want to use it. The patient would have to sign a document where they say that specifically, I voluntarily do not want to use my Medicare and I will pay you, doc, for these services. What has to be 100% clear is that it's voluntary. We didn't force them. I think that always makes sense. No one's forcing that. But you have to make it clear to them that once they do this, this visit can never be billed to any insurance, Medicare or secondary or otherwise.

There may be a few people interested in that. And so that certainly can work. But I still think the majority of people, once they get Medicare, trust me, will say, I'm going to use Medicare. And I'd say, do a simple survey. Anyone listening, just start asking your friends, when you go to the doctor, do you pay cash or do you use insurance? And I would ask everyone listening to think of the same thing for yourself. And I'm going to ask you, when you go to the doctor, do you use insurance or do you pay cash? And now a really quick word from the sponsor, ProCower Online. Don't go anywhere. I have a special offer for all the students out there. As you guys probably already know, I'm a partner in ProCower Online. I don't make any money from the podcast. I think I've been very clear about that from everybody. This is just a pure passion project. However, I know that I've, you guys, some of you have been to my workshop before. I had a workshop, a couple of workshops last year in my office. And then so we went over how to offload neuromuscular pathology and desensitize it with loading protocols. And so when people came to it, they're like, man, I'm really, why didn't I learn this in school? You know, like this, where am I supposed to learn this again? Besides coming to your place? And I was like, dude, I can tell you the references of where I got it. But at the same time, I don't know too many places that actually teach it. And so when I got a lot of those questions, we didn't have necessarily yet, but we do now. A lot of the lower extremity protocols that I use for loading come from Cody DMAX strength conditioning for the flexion tolerant low back, which we do have in ProCyro Online. It's $99. But for the first 50 students, and again, I apologize since we're into January now, we started having this in December. All these spots might be gone by the time we have this podcast release. But I'm going to take the gamble and say maybe there's a couple last spots there. So go on there, go to ProCyro Online, and you'll be just go through the link that says flexion intolerance spine, Cody DMAX strength conditioning. Use the coupon code FHMPodcaststrength25. And it will each student that does it up to 50 people, you'll literally get it for $25. All right. I don't make a single penny on that. None of my partners do. Cody will. Cody will be paid back. And I do think that Cody did an amazing job moving. I flew out to Dallas. We got a gym that we could do it in. We rented some lighting kits.

We got a couple models. And we spent an entire day doing it. And I edited the hell out of that thing. And I learned stuff. All right. And I think going through this whole podcast journey of my own, I've learned more than I ever thought I would because I didn't know what I didn't know yet. So, please go on there and take advantage of this offer. $25 for this is a damn steal. All right. You'll never find it cheaper than this. All we're looking for is for feedback. We're doing this because we want feedback on how to improve the modules as they come out. So, all the students, if you are a student currently, or if you have not been in practice that long, i.e. under six months, please go through and use this coupon code RHMPodcaststrength25 and let them know that Seb sent you. Now, back into the show.

I'm like you. I have not gone. Yeah, you haven't gone. But when you've gone? When I've gone. The last time I went, I actually did pay cash. And I opted to not even have them bother because mine was a catastrophic insurance policy. I assumed they would not pay for it. But see, that makes sense. You're saying, hey, people who have catastrophic young that otherwise don't use it might do it. But as they get older, do they do the same? So, you're kind of unique. You're young. You're healthy. You're also a chiro. You don't go to the doctor. Yeah, we're a bad target person. I mean, your other friends who are younger. And I just say it from this standpoint to get a good understanding. And it's not to say don't do cash, but understand what you're battling.

Most of your friends are going to say, no, I'm going to use insurance. So, therefore, you know, you're going to have to hit a certain specific demographic to make it work. It doesn't mean it's not there. It's like Whole Foods. There's a demographic for it, but you have to be in the right spot. Like, there's a Gelson's in Laguna Beach that does really well. Well, yeah, because in Laguna Beach, in fact, my wife, my grandson goes to the same school my kids did in Laguna Beach. And she sent me a picture yesterday from Carla, you know, when they pick the kids up in the afternoon. And I'm like, what is this picture for? She goes, look at the cars. There were three cars in line. One car behind her was a Maserati. The car in front of her was a Bentley. And the car to the right was a Rolls Royce. These people living with, I'm like, wow. Okay. So that's why Gelson's work. So you have to know that if you were in a car line in Santa Ana, that's not going to fly. There's no Gelson's there. So, so long as you understand your demographic, I think you can make it work. You just have to know, how do I get these people? There's a reason when you go into Newport Beach, there's Lamborghini dealers and there's a, you know, McLaren. You don't see those in the regular spots.

Know your market, know where you're going to hit these people. They can all work. I will certainly tell no one. It's just knowing that, is it a little bit easier to get people that have insurance? Yes. The problem is deciding which one is good, which one is bad, which ones I like. And this means go out and talk to people, ask other doctors, Hey, which one works for you, which one don't. And, and as a general, when you talk to anyone, they're going to hate ASH, but I'll say, know the demographic. If you open up an office near a Kaiser, you probably better take some ASH because Kaiser does not open facilities where there aren't Kaiser people.

Yeah. Um, two more questions on Medicare and then one different question and I'll let you go. I promise. Um, the, uh, for Medicare, when, when you're talking about someone comes in the $40, um, um, non-par and then they eventually get to the maintenance. We talked about federal earlier. So prepay package on those people is not allowed or. Well, now once Medicare doesn't cover, I would at least make the argument I potentially could because now Medicare does not control the patient or the price when it's not covered by Medicare. Got it. So then, so then they can do active care as a secondary thing on those visits too.

And that's a Medicare patient while under Medicare, you can do active care. They just have to pay out of pocket for it. So by example, a Medicare patient comes in, I adjust them. I get 40. If I'm doing a therapy, I could charge them 25 or 30, whatever I charge. Other patients are the same. So it's not that you can't do it. Just remember that's a hundred percent paid by the patient. Right. Well, could you get 75 out of a Medicare patient? Sure. 45 for an adjustment, 30 for exercise or something. Sure. Okay. This is the last thing because I think, um, as I have interns coming into the office, I realized the, um, and I'm in the same boat. There's things that were kind of told in school that are confusing, that scare us out of this whole insurance thing. Um, there's this whole concept that I remember that scared the bejesus out of me, which was the dual fee schedule argument.

Um, which basically like we kind of talked about cash discounts and prompt pay and blah, blah, blah. Um, but when, when we were at your workshop, we're kind of talking about different insurances allow different rates. Um, is that, um, so let's clear that up. I think where it's sort of funny when you think of it, and this goes back to insurance. Technically you can't have a, you know, a different fee for the same service when it's of the same. So by example, if you have a blue shield patient, all blue shield patients are the same because that's what the insurance allows you're in contract. But let's, let's think of it this way. Let's take California out because California, we know we could have a cash price, but let's say we have an office. Do you have your regular insurance rate? Of course you do. Could you have a small difference for a prompt pay? Okay. But let's just say you have one rate, but now that one rate, doesn't that rate change? What if you have a work comp patient? Doesn't work comp have a set fee schedule. So regardless of your $75 fee, if you were to take a work comp patient, you would get $57 for that adjustment, even though it's 75. Now, could you bill work comp at 57? You could, you could also bill them at 75, but they're still going to pay 57.

So in other words, what I'm getting into is that you potentially could have multiple fees for the same service based upon your contract or based upon the type of patient. So for instance, a work comp patient, a Medicare patient have set fee schedule. So regardless of your regular fee, that's a different fee. So that technically is a dual fee, but legal because it's contracted. You could have all the fees for the insurance you belong to. So if you belong to Blue Cross, that's one allowance. ASH is another allowance. What you can't do is have two of the same at different rates. So you can't say, Hey, I like this cash patient more. They pay 20. This other cash patient pays 30. No, well, they all pay 30 or whatever the price may be. So they all categorize them. But in a weird way, you really can have multiple fees based upon contracts, non-contracts. Everybody's the same, but everyone within the contract the same as well. So, so let's say you have your, your Aetnas and you have the, so we're talking in or out of network in, in this case, or just only in network is like in network is right. So if you're out of network, the fee's always the same. So let's say by example, I built three insurance companies, $75 for the same code.

Each insurance is going to pay something different. So let's say one insurance pays 50, one pays 60, one pays 65. Now I built $75 because I'm out of network. Since the one insurance paid 50, the patient owes me $25. The other insurance paid 60, that patient owes me 15. The other insurance paid 65, that patient owes me 10. In other words, when you're out of network, the fee is the fee. I bill it, the patient has to pay the difference. Got it. So that makes sense. This is why people go in network because let's say for instance, I charge 75, but the in network rate is 50. That means the allowable rate is 50. And then the patient pays their small copay. Let's say it's 10%. They pay $5 or 10.

So it's more attractive to stay in network. And that's why people often choose it because it's just more cost savings to them. They don't have to pay because out of network doctors, technically you have to collect what you bill. So when you're out of network, by example, and the insurance, you bill the insurance $100. If the insurance pays 50, the patient owes you 50. If you have another patient, you bill a hundred and the insurance pays 70. In other words, you can't take what insurance pays is payment in full because there's a portion of patients to pay, which is the difference. Now, this is again, why people choose in network because now the in network providers have limits based upon the contract, which make it more viable for the patient. And this is the tough part that I have an office right now that got themselves in a lot of trouble in Florida. And what she was doing when patients would come in, she would often, she was being nice, but if a person had a $500 deductible, she would just kind of absorb it because she was billing the insurance for 2000.

So even though she wasn't getting the 500, she was still getting about a thousand dollars. So she got, well, that still seemed fair to her where she got in trouble. They got her for a kickback. And the reason it was a kickback, if you have a $500 deductible that I don't collect, it's like I gave you that money as a gift. Right. And so by example, if I said to you, Hey doc, I got a patient, I want to refer to you, but I want you to give me a thousand dollars for me to refer it because the case was 10,000. That will be illegal for you to pay me because that is now a kickback. You're paying for the referral and for professionals. We can't pay. You can't say, Hey, go out every patient to refer to me. I'm going to give you some money for it. And this is where attorneys, anyway, this office got themselves in a lot of trouble over that. I think she did it very differently in a way, but it really was a problem because what she was figuring out is that it was her way of getting the patients in since they didn't have to pay their portion. The patients were willing to come in and they argued that probably she overbilled to make up the difference.

Okay. That makes sense. That was a, yeah, they don't clarify quite that much in school. And it's a, it was a big, one of the reasons I try to lecture because you don't, and you, what I will tell people is please take a moment. We, on our website, I have a news section, but be careful of blogs. There's nothing wrong with them, but often just because someone can put out information doesn't make it correct. Like we have a platform today and I'm thankful for being here because my hope is that I'm able to give people ethical billing and coding. I'm bound by that. I'm, I'm certified within every state to teach these courses. I don't want to put you in any position that gets you in trouble because technically if I do, I become liable. So if I teach you something illegal, you could go back and say, Hey, this guy taught it and therefore I could have some liability to that. And so I'm not going to put myself in that position. At the same token, you'll hear a lot of bad information because someone will say, I've been doing it for years. Well, that doesn't make it correct. Here's an example. I use it as seminar shoplifting can seem legal until you get caught. For instance, you might say, Oh, I thought you could take a pack of gum every time you went to the cash register. Now you could argue you didn't know any better, but that doesn't make it legal because you get away with it. So I think a lot of times offices do things that are outside the law that are in what is a gray area. Now, when I say gray, gray means it's black. We like to pretend it's like the love, like it's not as bad a lot. It's still illegal. So I told just don't risk your livelihood over one or two cases. By example, I had an office years ago, he had a really good practice, but he played some games on some PI cases that represented probably one to 2% of his income.

So for one or 2% of his income, he risked the whole thing. In fact, lost his practice. He actually spent some time in jail overdoing some kind of kickback issues. So I always warn everyone, think of it this way. Make sure you're just don't cheat anybody. Make it fair and reasonable. Even if you gave a bigger than you're allowed discount, I would argue so long as you didn't bill any insurance. I could help defend that to an extent. So make sure that it's just fair and reasonable. Come up with a good, fair fee that people will pay. And if you're finding people aren't coming in, maybe the fee is too high or maybe you're in the wrong area, you're going to adjust accordingly.

And that's part of how businesses work. You've got to hit your market. Okay. All good information. I'm actually going to break this into a two-part podcast. So I think you're going to be on two sequential weeks. Okay. No problem. Thanks. Once I get going, believe me, I'll go for a while. Well, I don't want to take too much of your time. I hope this was enough for everybody to realize they should go to one of your workshops. And is there anything else you'd like to share before we... Go to our website. Take a look. My email's even there. If you have something that you're not sure about, please reach out to me and just reach out and send me an email. My email is sam at hjrossnetwork.com. So my first name's Sam and then at hjrossnetwork.com. But reach out to me and say, hey, Sam, I was listening to the podcast. I have a quick question. Preface it that way, because technically I do a business that answers questions that way, but I never want to have someone that needs a quick answer or something that could be a big issue for them because I want to make sure you're doing it right. I also, I have an ulterior motive. By doing this, by people coming and even sending an email, they're going to go, wow, that was the best information I heard and will likely come because I'm creating an environment to make sure there's a value of what I teach for you because I want you to be successful. I work with a malpractice insurer, National Chiropractic Council, ChiroSecure. And one of our mandates are, we want you to practice. We want you to be successful because if you're not doing that, you don't need to buy insurance. You don't need to come to seminars. So we have a symbiotic relationship. My goal is to make you better. It's not too, this is why we've been around so long. There's a lot of seminar businesses come and go because they always want to play little games like, ooh, sell, you know, orthotics, do this, that. No, do good care. Make it fair. This is a profitable business. This is something that my hope and every young chiropractor, my goal for you would be within your first two years of practice, if you're working for somebody, if you're working on your own, you need to generate at least 150K of income minimum.

What does it take to do that? About 30 patient visits a week, which is not very many, by the way, if you're doing only 30 a week, you're twiddling your thumbs a lot. So therefore I would like to see most people doing hopefully 50 to 75, but building up to about a hundred to 150 patient visits a week. Now, some offices truthfully can see a hundred patients a day. Okay. But I would say if you're doing that like 25 to 30 a day, you have a successful office. You will enjoy what you do because people like coming. The one beauty of being a chiropractor, people come in your office and leave happy because they literally feel better. That doesn't happen anyplace. There's no one that goes to the dentist. No one goes to the medical doctor and leaves feeling better. So it's unique. And I think we have a unique perspective that we can help. We just got to get to more people and that's where the volume comes in. So it comes down to number of patients. So if you're doing 75 a day, if you're doing 10 patients, you just do the math and go, okay, how do I make this? Because you got to run a business. You're going to go, well, what does it cost me to own this building? Or what does it cost me to rent it? What are all my other costs? You know, phone bill and work that in. And you've got to look and go, what does it cost to treat a patient? So let's say it costs you $4,000 a month to run your office and you see 25 people a week. That means it costs you $40 a patient. That means if you join ASH, you're losing money. You have to make sure the volume is there. It's like everything else. The greater the volume, the lesser the cost. Go out and practice well. Treat your patients well. Get them better. That's the main focus. But understand the billing and coding part, which shouldn't be hard.

It's just, there's unique things about it that most people get frustrated with. So we're here to kind of help that. So if something comes up, you're not sure, don't be afraid to reach out because we want to make sure I'm careful that I see doctors get in trouble. I deal a lot with audits and that's always the negative side. I hate talking about it because it makes people bummed out, but I do deal with it. But realize I'm also, it's like, if you're an attorney, you deal with always your defendant attorney, you always deal with kind of bad things. But I want you to remember that that's still not the majority.

The majority of doctors don't get audited. The majority of doctors don't have any issues. It's when someone does something egregious. And we use a term here at the malpractice company, pigs get fat, hogs get slaughtered. So if you keep yourself fair and reasonable, that's where things go well. So think of your practice in that way, just like the school. In fact, one of the things I think is interesting, schools work on the insurance model. I did a lecture last week to the council of colleges on this. And I said, look, chiropractic college is very expensive now. When I went, this is talking the early eighties, it costs 1500 a trimester. My dad wrote a check for 400 bucks a month. My whole thing was paid no loans, nothing. Now it costs, I don't know, 40,000 a year. So by the time you leave school, you have 200,000. So a chiropractic college would not exist without third party reimbursement.

Yet so many of them promote, oh no, you're going to do cash. Well, the cash model doesn't work for school, does it? No. And part of that is because of the way this industry changed and the cost. I get it. So I want you to think of the same way, have a business model that allows you to do what you do and make it work. You can make a cash, trust me, a cash practice can work, but you have to think of it differently. What I would suggest is there's nothing wrong with having 50, 60, 70%, but don't turn away that kind of gravy insurance style. So here's what I would suggest for any office. My rule would be, I would join Medicare because it just accesses patients. Now, if the fee doesn't fit, okay, forget it, be out. But it means you're going to see very few older people. The other thing I would join is Veterans Administration. The VA under TriWest or Optum Health, depending on where you're located, I would join that. The VA generally is paying, depending on the services you're providing, but about an $80 to maybe $120 visit. I would take that. I would certainly join, generally in most states, your Blue Shield, Blue Cross programs. Now, I'll be careful. California is a little different.

California, I wouldn't join Blue Cross, but I would join Blue Shield, but I would not affiliate with the ASH parts. And I'm not saying no to that, but I'm just saying in general. I would not join UnitedHealthcare or Cigna or Aetna because at this stage of the game, those plans generally have better benefits and pay more for out-of-network. So before joining something, always look and go, will this plan pay me if I'm out-of-network? And if it does, chances are it's better to be out-of-network. But if you're in-network, what are the benefits? Will it direct more patients to me? So it's playing that role of looking, what are the pluses and minuses? In other words, every chiropractor upon graduation, in a way, becomes a CEO. And you have to make CEO business decisions about cost. And how do I get in? What's the numbers? It's something we don't like doing, but you've got to do. But once you kind of get that dialed in, you can do well. And go out, mentor yourself. Chiropractors are nice people. Go to an office and show up and say, hey, you know what? Can I just sit with you for a few minutes and ask you some questions, even on the phone? Most chiropractors are fairly generous with their time. And they'll be willing to tell you, hey, oh my God, this didn't work. That didn't work. And that's partly what I think podcasts like this can do, is to give a perspective. I won't say I know everything, but I know some information that is probably useful. Take part of what I've given and say, hey, I'm going to make that work. Others not. The thing that made me really happy, I had a young doc that graduated from, I guess he went to Palmer and he came to my seminar. He's gotten married in the last year and he goes, it's the only seminar that made money. It was so successful. He brought four friends and he brought his new wife. And his new wife literally said, coming to your seminar was a game changer because he went from working for someone making like $75,000 a year to where his practice last year did $400,000. Now, how did he mostly do that? VA, to be honest. But he was a veteran, so he had access to that. But he goes, wow, what a difference. I mean, he went from 75,000 to 400,000 in roughly a year and a half. That's phenomenal. How did that happen? He's seeing 100 plus patients a week. That's how it happened. Nice. Good stuff. Thank you. Thank you for being on, Sam. That was great, actually. Yeah, great. No, it's my pleasure to be here. I would say I'm not afraid. I like doing these because it helps me, you know, that more people hear me. Good.

But also, I want to get information out because I think there's too many things that are not correct or make people think one thing and it's someone has a motive to do it for you that way because they're making money on the back end. So there's always those things. Don't be afraid to have a jaded eye. And I don't, I would tell anyone, don't be afraid to say, you know, I'm not sure that Sam guy knows what he's talking about. Question me. It's okay. Because that way, you know, you've vetted the whole process. Right. Yeah. Perfect. Well, so yeah, everybody should go to a seminar. I went to this one a couple months ago and I did join the network that he's talking about on his website too. So I know that from personal experience of we've done billing with a, we hired a company to do the billing on the other ends. It's worked well for many years, but at the same time, it's been, I've thought of bringing it in-house and it's kind of menacing. And so having Sam on the other side of just being able to ask questions too is very helpful and it helped guide us by doing an office. So cool. Well, thank you so much, Sam. All right. You're very welcome. My pleasure.

All right. And have a great rest of the day. You too. Thank you. All right. Take care of my friend. Bye. Bye-bye. Sam, thanks so much for being on. That is the conclusion. God, I wish I could have you longer. So everybody, hjrosscompany.com. He has a whole list of workshops to go to. And I can tell you, honestly, I'm going to go next year. I fought the idea of going to workshops like these for a very long time because I just thought, you know, I probably think what you guys think a lot. It's like, oh, insurance, don't want to deal with it, you know. But I think being informed about what's going on is better. It's easier to navigate and communicate with your patients about it. So give them their options. And for all we know, maybe the insurance will help cover a lot of their care or parts of it. We don't know. And I learned a lot from the workshop. So I think that's something that you guys should really go to. I don't get any money for recommending it.

And as you probably know, since I've said in the past, I don't make any money from this website. It's just learning. And I think I've gotten a lot better over the years. Now, last thing before we actually go is that, again, this weekend, this is releasing the Wednesday prior to the movement meetup. All right. You're part of the movement. If you're a listener, if you're a hardcore listener, you're part of the movement. And so we're meeting up at Sandy's and Huntington Beach right at the end of the pier this Saturday, the 18th of January at five to seven o'clock. You don't have to RCP. You don't have to message me. You don't have to pay anything other than your own beer and food and so on. All right. This is not an official workshop of any type. It's just, wow, hey, I can't believe you're here too type of thing at the bar. Right. I believe as we can really nurture each other's growth by just getting to know other types of health care providers and strength coaches and specialists who are in the community. And so I'm probably going to have a podiatrist come, a family practice doctor, a couple of strength coaches, DCs, PTs, DC students, whatever.

You know, I think we can all bro down and I think I can learn a lot from you guys. And hopefully, hopefully if you have questions for me, just ask me and I'll be as raw as I can possibly be. So we're going to do that. Again, invite your friends. I would love to meet all the listeners. And this is probably the easiest way to do it. Again, no cost for you guys whatsoever. But I'll be there in a blue hat, I think. I hope I remember that. I'll be there in a blue hat. This says Barons on it. Royal blue because we're the Royal Barons. Last part is that you hear the sponsorship happening over and over again that I'm talking about. Okay. It's Pro Cairo online. I don't literally don't make a penny off this podcast. I don't have any, like I don't get paid for that sponsorship. And the only reason I have it on is because I really truly think that you guys should learn, should take it. And you'll learn, a lot of you will learn a lot of great pieces of information from that. I know that by doing this podcast over the years that I, there's a lot of things I thought I knew and I didn't know what I didn't know. And it's been very enlightening. And so going through that, there's been a lot of enlightenment moments that I've had. So I want to share that with you guys. And so take advantage of all the deals that we have currently in the beginning of the year here.

There's the ethics one as well as the strength one. If you're looking for the ethics one, go talk to Philip Snow on Facebook. He has the details about that one. I'm just in charge of the strength one for students. But thanks for listening, guys. Share the podcast with another DC that you know, and keep growing the podcast, keep growing the movement. I'll talk to you guys next week.