I wanted to have a little post/discussion of some of the things that happen on a daily basis in the office that most people don’t understand or think about when they come in for a visit. I recently received an email from FMCSA (Federal Motor Carriers Safety Administration) that they will be doing random audits on medical examiners that perform DOT physicals.  We have also seen an increase in insurance audits and preauthorization requests from companies themselves.

This type of screening scares the hell out of providers, even if you feel that you are doing things correctly and ethically. The last thing any business wants to have is to open up their records with the possibility of money claw backs and threats of taking away the ability to perform specific tasks within the office.

The question arises all the time, “how come you only give me a one year or three month card?” Well, I don’t make the rules.  The enforcement arm is always on the back of the mind. Blood pressure medications, CPAP’s, certain types of diabetes and other past history can bump certifications all over the place. Just because you passed the test and have been performing them for 12 years, doesn’t mean that they just let you keep doing them without some oversight.  There is A LOT of wiggle room with these physicals and we feel that we perform them to the best of our ability.

The other issue that we are constantly running into, the ever evolving health insurance model, I’ve always said “I just need to know the rules to play the game but a lot of the new insurances don’t tell you the rules, you just figure them out as you go.” There are new preauthorization requirements for certain insurances and “palliative care” is starting to get cracked down on quite a bit more.

Maintenance care has never been allowed by the majority of carriers, so if you plan on coming in every two weeks on the dot or schedule a month out for your next appointment because you just “like to be adjusted,” insurance has not and will not pay for these services.  You are more than welcome to come in and be adjusted as much or as little as you would like but just know that we, as an office, are starting to look patient by patient of things that would qualify as “maintenance care” and cracking down on it ourselves to limit the possibility of audits.

Some plans allow for a certain number of visits throughout the calendar year or give you a set number of visits over a certain number of weeks, but this doesn’t necessarily mean that this is what your insurance will pay for. We do not set the limits on your plans, we submit and attempt to do the background work, we are not picking on you if you get a bill but you don’t think you should get one because you think your insurance will pay for it.

These plans are starting to be very confusing, not just for you but for our office as well. This blog post is by no means a way of discouraging but more of a reminder that we don’t set the rules for the insurance that you or your employer signs up for. By being an in-network provider, we agree to submit and essentially hope for the best.

In ending, audits within the Federal government and private insurance companies appear to be on the rise, due to overuse and blatant fraud.  We are doing the best we can to work within the guidelines that are laid out for us and we are not necessarily picking on you or your situation. We do the best we can with the rules that are set out for us.