Dr. Allen Miner:
Hi everyone. I’m Dr. Allen Miner with Brian Capra. This is the Best Practices Segment of the UAC Podcast. We’re with Dr. John Davila. Give us an intro. Dr. Brian.
Dr. Brian Capra:
Hey everyone. Dr. Brian here. Super pumped. This is Best Practices and hopefully you will get a little nugget, a little piece of something that you can learn, implement, or teach others that can be part of their best practices. So, really excited to have John Davila on today, we go way back. John, we have some really good stories together, and I know you have so much information and you’ve already added a lot of value to the UAC group, just bringing what your expertise and knowledge. We just had an amazing event in New Orleans and man, the genius in the room, but you’re one of the big ones there. You bring a unique perspective working with as many doctors as you do. So, I know it may be hard, but try to pick something that docs hearing today could implement in their practice or learn or maybe gain a new perspective onto their practices, given all your experience.
Dr. Allen Miner:
And John, before you start, if somebody doesn’t know who you are, give just a quick background. Who are you then jump in, please.
Dr. John Davila:
Sure. I’m a Palmer 94 graduate in Davenport, practiced in Myrtle Beach for 13, 14 years, or something like that. And then started finding reasons why people were getting denied for claims, especially myself, and then started to learn the inside as to why. So, when it comes down to the reasons why people get denied claims or the reason why people get asked for documentation, it started to dawn on me that there were a bunch of things that were different compared to what I was doing beforehand, and then what I was doing after I learned. And that started to be the beginning of what needed to be a change. Because what’s funny is, especially when I try and teach this stuff because I mean, I don’t know if you guys know this, but sometime May or June next year, I’ll hit two million miles on Delta, which is not really a badge of honor.
Dr. Allen Miner:
That’s massive.
Dr. John Davila:
I glow at night, by the way. But I’m just saying. But what’s funny about that is because I travel so much, I see so many different people. What’s interesting about it is you start to see that the complaints and the worries are the same regardless of whether or not the doctor is a cash practice or insurance-based or PI, it really becomes a worry, right? Do I have the right thing? And what I mean by in my world, whether it’s cash or insurance, what I mean by that is it’s a documentation risk management issue. And if you have the right information, you have the best scenario, so when anyone complains, here’s my stuff, and you’re done. So, I think one of the biggest things that I’ve learned recently is really trying to understand what other people think. And I think that’s really the biggest issue, that we forget, that we have our thought process, we have our mindset, and we’re trying to do what we want to do over and over and over again because we’re trying to affect our… You get this big effect on our communities.
The only problem is from a risk management standpoint, it’s not what we think that’s the problem. It’s what other people see when they look at what we do that’s the problem. So, one of the things you could really look at, and I just had this weekend when I was teaching in Florida, it was really interesting to have this conversation with about 70, 80 docs in the room. And I go, “What’s the biggest reason why people don’t respond to a letter from let’s say Medicare or from anybody for that matter?” And the answer wasn’t that they were worried about getting denied, they were worried about anything else other than, “I don’t know if my notes really match what’s supposed to be there.” And the question isn’t now, well, should you have the best notes? The question is from an expansion standpoint, right? How do you get to that next level?
The question is, well, what do you do from a mindset standpoint to make sure that you don’t have that worry? Because from a mindset standpoint, it gets to be the point where you’re afraid and you won’t expand, you won’t really, really push because as soon as you push, the universe is going to push you back. And if you don’t have the ability to go ahead and answer that push, then people will just kind of like, how can I say this? Well, kind of like a cruise. They won’t actually push going forward.
Dr. Allen Miner:
If I tease out what you’re saying, one of the things capping a lot of practices from growing is they’re not confident in their liability of note-taking. So, they’re almost subconsciously sabotaging themselves.
Dr. John Davila:
Absolutely. And I know that’s-
Dr. Allen Miner:
That’s crazy. I’ve never heard anybody’s related notes, Medicare, Medicaid, or insurance to practice growth. I’ve never heard that connection before in all my years in chiropractic.
Dr. John Davila:
Well, I mean-
Dr. Brian Capra:
Do you know what’s funny? If I could add to that too, John.
Dr. John Davila:
Yes.
Dr. Brian Capra:
And you know this very well, we see the same thing on the Genesis side where we’ll ask last doctors, “Hey, you’ve seen all these patients and you have thousands of visits you’ve never billed, what’s going on?” There are just claims that even if we did nothing for you to help, you’re going to get a bunch of money if you just submit the claim. And it comes down to they’re just scared. They’re just scared of what happens when they hit the button because they don’t really understand the whole thing. They don’t really understand and I think what you bring up an excellent point is to understand what the other side is looking for. It’s not a war. They’re not trying, they don’t want to put you in jail.
Dr. John Davila:
No, they don’t.
Dr. Brian Capra:
They just-
Dr. John Davila:
Go ahead, Allen.
Dr. Allen Miner:
Yeah, let me tell you how I perceive it, which I think is in line with a lot of chiropractors. And then I’d love you to say, “Yeah, you’re right in line, or no, this is where you’re wrong.” I run cash practices primarily. We do a little bit of personal injury. So, what I was always taught is you must do an exam, and document that. The findings you have a need to match the areas you found problems with, and then your treatment needs to correlate with those areas. So, the range of motion’s not right, so I’m going to code for something saying there’s a problem in the neck, and then my treatment is going to be related to the neck, and my notes need to have that congruency. I know that’s a big oversimplification, but-
Dr. John Davila:
That’s true.
Dr. Allen Miner:
So, then can you color commentate what am I missing in that oversimplification, or what’s often missed in that arc? Or where do people misstep that keeps them from growing because of what Brian just said? Now they’re subconsciously going through my notes, I’m nervous they’re even going to stand up against anything, so I don’t want to send them out.
Dr. John Davila:
Right. So, okay, here’s the thing. There’s a difference between someone who’s been out a while versus someone who has not, right? So, we deal with a lot of new graduates and when they come out, there’s a phrase that I always say to them, “If you didn’t write it down, it didn’t.” And they always finish the word with “Happen,’ right? They’re not infected with that bug of, we’ll call it practice, right? The bug of practice where they’ve seen it over and over again. So, if you give these people a process, they’ll continue with the mindset that if it didn’t write it down, it didn’t happen. They don’t know that once you get out of that and believe it or not, one of the fewer percentage of people that actually have that thought process down I would say. The majority of people that we see that come to us don’t really take notes in a way that makes sense because they use the same as the last treatment button and it’s the same, the same, the same, the same, the same, the same.
Because the problem is that no one’s ever asked them for anything in so long that they don’t care or they’re a self-pay patient and no one cares. And it doesn’t really make sense until you start to step back from what you’ve done and sit there and you go, okay, wait a second. Hold on. The only person who’s ever going to ask me for notes is going to be in a self-pay situation, right? Is going to be the board, right? So, my question at that point in time when I talk to someone is, well, if they did, what would you be able to give them? Because a note review is no different from a DUI. I mean, you get hammered at the bar, you get in the car, and you drive home. The first person to ask you what your blood alcohol level is, is the cop, right? And by then it’s too late. The same thing in this situation, from a documentation standpoint, in the back of their mind, the doctor has gone from, if I didn’t write it down, it didn’t happen, right?
Two, no one’s asked me for anything, and I’ve become lazy, right? This is just not an overgeneralization, just what’s happened, right? So, at that point in time, they’ve started to drop things out. And because they drop things out, they know in the back of their head that, Hey, if someone asks me, I may not have everything. And I know this for a fact because when I go teach this, I ask that question because the numbers lay it out. Right? So, when Medicare asks for documentation, the post-payment denial rate’s 82%. So, after a hundred claims are paid, 82 out of a hundred get denied. But here’s the thing, you ready? Of the 82 claims that are denied, 88 are because no one responded. 88% of the claims because no one responded. So, what does that mean? That means that people are just like, I don’t know, so I’m just not going to do anything. The only problem with that is if you don’t respond, that’s an automatic denial. You got to pay the money back anyway. What that means is 12% are getting all the approvals.
So, the truth is that they’re not like Brian says, they’re not sending people to jail for this. And if you do take decent notes, you are probably going to win. So, it’s all in the process, I think in the transition from new graduate into I’ve done this for so long, I used to have this thought process of I do everything and I write it down because of if I didn’t write down, didn’t happen into I kind of take shortcuts because no one’s bothering me. And that’s a process that people have got to look at and say, okay, I’m done with that and I go back. And then what’s funny is when we work with people and we get them to that process, we’ve seen them actually do a couple different things. And this is one of the situations that’ll happen with people that work with us and people that I see over and over again at different seminars and they implement.
Because when I go teach, I don’t give them part of it. Here’s everything, go do it, right? So, what’s funny is when I talk to friends of mine that I like fraternity brothers of mine and I tell them what’s going on, they come back to me and they go, The data is the same.” They come back to me and tell me what the data is the same as my clients, right? They see less patients, but they make more money because they didn’t know where their holes were as far as where they were seeing patients for free when they shouldn’t have, where their documentation didn’t match, where they were having seeing patients but their denied claims were coming in, they didn’t know. And if you take all of that, what ends up happening, Allen, isn’t just the fact that it’s his mindset, it’s also a clutter issue, right? So, if you’re seeing patients for free because you’re afraid to send claims in, that’s a clutter issue. Creating clutter, it doesn’t allow you to see more new ones.
Dr. Allen Miner:
And Dr. John, quick-
Dr. John Davila:
[inaudible 00:11:42] from a dollar standpoint.
Dr. Allen Miner:
Makes perfect sense, man. Absolutely. Here’s a question, what’s a cash practice seen somebody for eight years on wellness, they just have their notes salted, repeated.
Dr. John Davila:
Yeah, yeah.
Dr. Allen Miner:
What should they be doing on a simple level? What should be in those notes, so that’s not the same note reprinted for seven years?
Dr. John Davila:
Okay, watch this. One of my favorite quotes, I’m going to tell you a quick story. One of my favorite clients ever, he had this happen. He was really, really busy and he got asked for notes. And when he got asked for notes for a patient that was a self-pay patient, right? He had a problem because he wasn’t taking notes. It was like salt, salt, salt, salt, salt, salt, salt, salt, salt. And the documentation didn’t match the note, right? And it got to the point where it was just the salt, salt, salt, salt, salt. It wasn’t a note, it just segmented like a date and segments, right? So, when the board got ahold of it, they were like, “Hey, wait for a second, there’s nothing really in here that makes sense. Why aren’t you taking notes the way you’re supposed to?” And his answer was, “I’m too busy.”
And to be fair, I mean he’s seen eight, 900 a week and he was busy. Now the board says, “You got to hire someone to watch you.” He calls me up, “Will you come to watch me?” “Sure, no problem.” So like a babysitter, I’m sitting there watching him. And believe it or not, it depends on the code, right? So in 98940 land for active care, he takes a certain note and that note is to measure improvement because you could send that to an insurance company or just to show that the patient’s improving. In wellness care, it’s a different code. It’s S8990, and that code just talks about how I don’t expect any change, right? Because really the difference between active care and wellness care is what I expect as the provider, not what the patient’s going to give me, what I expect, do I expect to change, yes or no? So, in this situation, he was using the wrong code and then sitting there trying to answer questions that there was no improvement to be had when there was no improvement to be had. Do you know what I mean?
Dr. Allen Miner:
If he would’ve had the right code, he would’ve made it a lot easier on him.
Dr. John Davila:
Yeah, no kidding. So, all we had to do was change one code, and then all of a sudden he was practicing 80% wellness care anyway. So, we changed one code, and then we just changed the actual structure of the note and it became like a two-button note because the patient didn’t have any change. If there’s no change, there’s no reason to use 98940, which is going to ask me for same, better, worse, then why compared to the last visit. You don’t even need to answer that code, answer those questions for that code. So believe it or not, when I went back and I changed that one thing with him in one day, went back to him and then timed him for about a day and a half about how long it took him to do an active care note versus wellness care note, at 80% wellness care for 800 patient visits a week that one change saved him 13 and a half days a year in time that he was hitting a button that made no sense.
Dr. Allen Miner:
And now compliant in covering his ass.
Dr. John Davila:
And now he’s seaway. Correct. Exactly. So, in this game, it’s one of those things people think that from a compliance standpoint, they talk to me, I’m going to sit there and beat them with a compliance stick for six hours. I’m going to beat you, beat you, beat you, beat you because you’re out of your bad, you’re bad, you’re bad. That’s not the situation. The whole idea of compliance is that I give you the stick of compliance, so you can beat your patients with it. So, because you need to understand what you need to do, it’s you that needs to control everything else around you, not someone else beating you into submission. That’s not how it works.
Dr. Allen Miner:
The last question, we’ll let you go. And I know you got a bunch of these. What’s the worst scenario you’ve been brought into that had the simplest solution? I’m sure you’ve seen it all from doctors doing some really dumb shit, but what’s the one that’s like, that was really dumb but all what you almost just shared, if they just would’ve done this, they would’ve saved themselves all that headache.
Dr. John Davila:
Over documenting. Now, I’m going to say that, and then the answer is over-documenting. So, here’s what happens, right? People will go to seminars, and the reason why they hate my topic, and I get it, is because they’re always told, well put this in, put this in, put this in, put this in. And they put all this stuff in and they document, document, document, in the end, they step away from the computer and go, I don’t know what this is. Okay, it looks like it’s enough. And then they hit send and they’re done, right? I had this with one guy in New York state, and what was funny was he went to 15 different seminars and then went to someplace where a Medicare rep was going through it, and he added all the stuff, his note, his daily note, not an eval, his daily note was almost a page and a half long. And then he was wondering, why? Why am I getting denied? Well, I had to step back and go, wait a second.
Remember the idea of what they think of you is more important, right? Well, in this situation, I don’t care what you do. If you see someone once a week for three years, it’s never going to be medically necessary. The reason being is that there’s no change. The patient’s the same, the same, the same, the same, the same, same, the same. All we had to do was stop him from billing, implement a new system, explain to him what medical necessity was, and then say, “Okay, restart the process.” And as soon as he did that, he’s like, oh my God, my notes are like two seconds long and I’m getting paid, and the patients are paying for. “Oh, so it really wasn’t my notes, was it?” I’m like, “No, it wasn’t. It was what they think of you because of what you billed them.” And once we fixed that one thing and he fixed that one thing, it was so simple. And that was probably a 30-minute conversation to be able to have him understand what it is. So, the biggest problem is over-documenting because you’re trying to prove something you just can’t.
Dr. Allen Miner:
And I’ll give a quick just plug for Genesis and other EHR systems, that sure makes your life a lot easier when you just have a really good EHR system that can plug this stuff in. It simplifies so many steps, just the world today. John, if somebody’s like, oh my gosh, I need to find this guy. I got some questions. How do they look you up? Do you have a website? How do they email? What’s the best way?
Dr. John Davila:
Customchirosolutions.com, or you can email us info@customchirosolutions.com. You can find us on Facebook, all that stuff as well. But I will say this about Genesis. What’s funny is the first conversation, the first part of the conversation that Brian talked about was people don’t bill, that was actually the first case Brian and I worked on. Do you remember that one?
Dr. Brian Capra:
Yeah.
Dr. John Davila:
And seriously, Allen, I swear to you, and watch Brian’s head, he’s going to shake his head. The first guy did over almost, almost, almost over it was just about a million dollars a year in cash, but had another $600,000 or $700,000 in insurance. He never billed, but he did the adjustments. True or false, Brian?
Dr. Brian Capra:
Out of fear. Out of fear.
Dr. John Davila:
True or false, is that true? No exaggeration.
Dr. Brian Capra:
No.
Dr. John Davila:
No, that’s exactly what happened. And all you had to do was come back and sit him back and go, wait a second. Why didn’t you hit the send button? I was afraid I didn’t have everything.
Dr. Allen Miner:
Wow. That’s beautiful. Well, John, we love you. You’re the epitome of what UACs about. There are so many different people from different corners of the profession doing so many different things. And we love you, man. We love your genius. Thank you for dropping those nuggets. I know a lot of people are going to make more money from just listening to what you shared today. Thank you.
Dr. John Davila:
Make more time. Make more time, how about that?
Dr. Brian Capra:
Thanks, brother.
Dr. John Davila:
Even better.
Dr. Brian Capra:
Time and money.
Dr. John Davila:
Yeah. All right guys, thanks.
Dr. Brian Capra:
Thanks bro. See you soon. I hope to see you soon. Peace.
