This two-part series on Extended Health Care (EHC) will help you keep up with trends and work effectively with insurers across Ontario. In episode one, Dr. Moez Rajwani discusses how EHC is evolving and what that means to chiropractors like you. From cost containment to digital transformation, he highlights current trends and outlines what you need to know to support your patients and protect your practice. He also chats about the pros and cons of preferred provider networks and how big data is informing insurers’ questions and actions. Tune in to also hear about the rise of audits and how to prepare for one. And Dr. Rajwani suggests how your practice can use OCA’s Extended Health Care Guide and its tools, resources and information on leading EHC insurance practices to protect you and your patients. (25:35 minutes)
Key Links Discussed:
About Dr. Moez Rajwani:
Dr. Rajwani is Vice President of Clinical Services at North York Rehab Clinic (NYRC), where he manages and works with a multidisciplinary team of medical consultants overseeing complex medical evaluations. He also practises and manages orthopedic rehabilitation centres in the Greater Toronto Area (GTA).
He is also Executive Director of the Future Ready Initiative, which aims to increase the community’s preparedness, as well as its resilience in the face of disruptive changes in the area of the future of work.
An active volunteer, Dr. Rajwani serves as the Co-Chair of the Coalition of Health Professional Associations in Auto Insurance Services in Ontario and is a board member at Michael Garron Hospital. He is also on the Board of Directors for World Spine Care (WSC) Canada.
Dr. Rajwani is a recipient of the Queen’s Golden Jubilee Volunteer Award, the OCA Volunteer Service Award and an award from the Ministry of Citizenship for 25 years of service to the community.
He graduated as a Doctor of Chiropractic in 1994 and has post-graduate certifications in Occupational Health and Sport Sciences.
Watch for Part 2: EHC and Virtual Care, Post-Pandemic and More - coming on October 15, 2021
Episode 3: How Extended Health Care Trends Affect Your Practice
Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
I'm Leslie and today I'm speaking with Dr. Moez Rajwani, in part one of a two-part series on how extended health care is evolving and what that means to chiropractors like you. Dr. Rajwani is Vice President of Clinical Services at North York Rehab Clinic (N-Y-R-C). He also practices and manages orthopedic rehabilitation centers in the greater Toronto area. As an active volunteer, he fills multiple roles, such as serving as co-chair of the Coalition of Health Professional Associations in Auto-Insurance Services in Ontario.
From cost containment to digital transformation, Dr. Rajwani will highlight current trends and outline what you need to know to support your patients and protect your practice.
We'll chat about the pros and cons of preferred provider networks and how big data is informing insurers' questions and actions. And you'll hear about the rise of audits and how to prepare for one.
Most importantly, Dr. Rajwani will suggest how your practice can use O-C-A's extended health care guide and its tools, resources, and information on leading E-H-C insurance practices to protect you and your patients.
Thank you, Dr. Rajwani for taking the time to speak with me today. I understand that you've joined the O-C-A Extended Health Care Advisory Council. Now, what is the main goal that you hope the E-H-C advisory council achieves?
Dr. Moez Rajwani:
Thanks, Leslie, for having me on this podcast. The Extended Health Care Advisory Council is something that I was very passionate about and was very excited that the O-C-A was going in that route. And really for me, as I've been in practice for many years, I've realized that the interrelationship between third-party payers, such as insurance companies, chiropractors and their patients is one that is increasingly active.
And my expectations, my hopes, my outcomes of the E-H-C Advisory Council was really to bridge that gap between patient care, chiropractic services and third-party payers so that it's easy to understand. We understand the importance of each practitioner, each patient, each insurance company, and bridging that relationship so that chiropractors had a better understanding. And that was really my goal as I joined the team.
Now, when you talk about easy to understand, is there one key point that stands out as the most complex aspect?
Dr. Moez Rajwani:
Sometimes we forget that our relationship is actually only with the patient and that the extended health care carrier's actual client is the patient, not you.
And so what that means is it puts you in a bit of a crossroads because you're interfacing with the insurance company to get paid for the services that you rendered for your patient. And yet, there's so many rules that prevent you from contact, discussions because your relationship is with your patient. And so the complexity is that there's actually three people involved in this relationship. And we forget that sometimes. And so we get frustrated with an insurance company. That's the complexity of the situation.
And then the second is that each insurance company has their own rules on how they operate. It's not homogenous. It's hydrogenous. And it's not like when we look at our OHIP services where we have one public funder. In the third-party system, we have so many different funders and each one of them has their own rules of engagement.
One of the first initiatives that the E-H-C Advisory Council has done is produced a new Extended Health Care guide for chiropractors. How are you using the new O-C-A E-H-C guide?
Dr. Moez Rajwani:
I'm using it partly for myself and partly for my staff. How the guide is designed is, one, it gives you the overview of what extended health care is.
Now, for somebody that's been in the system as long as I have, I probably know that, but it'd be very useful for a new grad who's trying to understand what is extended health care? How does it work?
The second part talks a little bit about trends, and what's important and what's happening in the industry and that was a very useful exercise for me as I started to understand the context and the context has changed and it's evolving.
So even if you're an old-timer like me or somebody that's brand new in the chiropractic community, things are changing all the time. So what we've tried to do is at least as a snapshot, give you what's happening today around this area.
And then there's the practical, and this is where the staff comes in. It teaches them how to sign up with different organizations like Telus Health. It allows them to understand the role of billing and how billing works and what are the dos and don'ts.
And many of the chiropractors have excellent training programs for their staff, but there's a lot of changeover in staff. And what this does is sets a framework from which when you hire new staff, or you have existing staff, allows you to understand the methodology and the processes required to have a successful third-party model in your clinic.
Now, you mentioned the trends, what do you see as the top three trends today in E-H-C?
Dr. Moez Rajwani:
So top one is of course, cost containment. Insurance companies at the end of the day are a business and they're looking at ways of saving money. Employers who actually buy the product are worried about their premiums. And they're worried that the premiums they're paying for their insurance keeps going up.
And so this notion of cost containment, and how do you ensure that services that are delivered, are cost-effective and required has become a big part of the trends.
And in this there's a couple of things we see all the time. One is this word fraud and insurance companies continue to be worried about fraud and fraudulent behavior in the industry. And the second is create networks.
And what do I mean by networks? So insurance companies now want to have a finite understanding of how funding and costs are going to be. So things such as preferred provider networks are starting to become more and more common in Canada.
They've always been common in the US but you're starting to see them in Canada. So one is this whole area of cost containment and what works around cost containment.
The second is this whole area of digital transformation, digital literacy data. And what have we seen in that? Well, for one, in the last year all of us have experienced the whole notion of virtual and telehealth. That's a trend that we continue to see, but also in this area is the whole area of data analytics, artificial intelligence.
What we're starting to see is information that comes through informing decisions. So insurance companies are starting to collect more and more data from our patients and from ourselves to help inform decision-making. So there's way more data points and data analytics and decisions being made by data, which are happening in every industry, also are impacting our chiropractic industry.
So you're seeing this plethora of data. So that's the second kind of trend is around data, around the types of services we're providing.
And then the third is the types of care. So of course, mental health and mental health services is a huge trend growth in extended health care, not directly impacting chiropractors, but impacting the patients that we service.
And in that, we're also seeing things like health care spending accounts, where patients are now given choice. More and more we're going to start to see this notion where patients are given choice on how they spend their money.
So when I started, the only type of plans you saw was X number of dollars for chiropractic services, Y number of dollars for physiotherapy. Now more patients, especially people from the digital economies, such as the big tech companies, are getting health spending accounts where they say, "You have $1,500 a year," or, "You have $2,500 a year. How are you going to spend that money?" So now it's in the patient's hands on how they spend the money.
I'd like to drill down a little further on some of them. When you're talking about data collection, what type of information are insurers routinely collecting from chiropractors?
Dr. Moez Rajwani:
What I've seen and what I've started to see both in my practice and in some of the conversations I'm having with colleagues of mine, one is data around the service provisions we're providing.
It's not just they want to know that they went to see a chiropractor, now they want to know “what did the patient get when they went to see the chiropractor?”
So in some cases, they're looking at data such as: Are you using physical therapy modalities? Have you included exercise? And so one is around the types of care that patients are getting. The second is the conditions from which patients are coming to our offices. So what is it that we're actually treating? Is it back pain? Is it headaches? Is it knee pain? What are the services that we're actually providing?
Because they're trying to start to see what are those natural pathways that people are going. So if a patient has neck pain, are they seeing a chiropractor? Are they seeing a massage therapist? Who are they seeing for their neck pain? So the types of interventions is one.
The second is the type of service. And then they're collecting basic demographic data. How old is the average person that comes to see the chiropractor? How many kids are we seeing? So those are the types of things that I've seen in terms of the data collection.
What about the time spent on each type of service or treatment? Are you seeing any questions or requests for that?
Dr. Moez Rajwani:
Yes, I am. I'm seeing it more around the payment of the service more than the data analytics. So when I put a bill in… Let's say my service costs $50. A few years ago, they would say chiropractic adjustment $50 and they would fund it as long as that was in the plan. Now they want to know what did that $50 incorporate? Was it a 15-minute session? Was it a half an hour session? Many insurance companies and you see this in the auto sector as well, they're now going by time spent in terms of their reimbursement models.
Traditionally chiropractors have always done per service. Whether you spend 10 minutes with them or 40 minutes, your office bills are usually the same. An example of this is massage therapy. It's been on time. When you go to see a massage therapist, they bill you different for 30 minutes. They bill you different for 45 minutes. They bill you different for an hour. Insurance companies are now asking the same from chiropractors. "How long are you spending?" They want to know that and they're reimbursing based on time spent.
Now, is there anything else they're looking in the payment side of information collection that's new that they're asking for beyond time spent?
Dr. Moez Rajwani:
They're making sure that there's information around registration - who's providing the service. So they want to make sure it was actually the chiropractor providing the service, not an assistant who may have been doing all the work and the chiropractor came in for one or two minutes.
So they're being a little bit more picky now on who's actually providing the service. And then the traditional stuff: Is the date that they've attended the same as the notes you have? So when they get into actually looking into more details around a file or a case, they want to know what you've put in your SOAP notes, what you're doing on that compared to what you've actually billed for.
Now, is there anything that insurers are asking for that they aren't permitted to ask for in terms of data or information from chiropractors, that you've heard about, or is it pretty open that they can ask for just about anything right now?
Dr. Moez Rajwani:
It's an interesting question. I mean, consent of data, privacy are things that we always think about.
One thing all chiropractors should know is that when you submit a plan or if you've got the traditional old paper plan that the patient signs, that form before submission; if you look at the fine print at the bottom of that form, it really talks a lot about you giving consent for the insurer to investigate or ask further questions around the claim. So the answer is, it is fairly open-ended.
I think where we have to be cautious is that it's regarding the claim and the billing that happened. So when they start asking about things above and beyond the claim, or they want to see files in your office that have nothing to do with the actual insurance company, I think that's where sometimes it's a slippery slope and you need to consult at that time to make sure that you actually have consent from other people to give away that information. But the form itself when you submit a plan does allow quite a bit of autonomy for the insurance company to come back and investigate a claim.
Okay. Now you also talked in terms of trends such as a preferred provider network. Do you want to explain that a little bit further and maybe talk about what the opportunities are for chiropractors there, as well as potential risks?
Dr. Moez Rajwani:
Preferred provider networks have a variety of ways of operating. So let me give you some examples.
One preferred provider network is through what we call a request for proposal process. So an insurance company says, "We want to have preferred providers in the Kitchener-Waterloo area." And they come up with a proposal and clinics, chiropractic clinics, physiotherapy clinics, put in an application and then they select through their own criteria.
The advantage of something like that is that when they get a client that's looking for chiropractic services, and if you're a preferred provider, then they're giving you access. So it allows you probably to increase the number of patients that you're seeing in your office from that insurance company. So it's supposed to be a merit-based process that you look through a series of criteria that that insurance company has. And once you meet those criteria, they either have two options: one, they accept everybody that meets the criteria, or they say, "We're only going to pick 20 clinics in the Kitchener, Waterloo area..." as an example, "and we're going to pick the top 20 clinics."
So the advantage is that it allows you to be part of that small network that's going to get patients. The disadvantage in that model is that generally, they favour larger organizations because they're looking for multiple locations. And so if you're an individual, sole practitioner sitting in Kitchener-Waterloo, your ability to meet their level of what they're looking for sometimes is more difficult. Not because you're not an excellent chiropractor, but you may have an office that doesn't meet all their requirements. You may not have an exercise area in your office or whatever else they're looking for. Maybe they're looking for some kind of an accreditation that you don't have. So sometimes it limits your access to that.
So the challenge sometimes is with some of the individual chiropractors that have smaller practices that are hard for them to compete with a multicentre, multidisciplinary type of environments that also exist. So that's one type of preferred provider network.
The other is not really a preferred provider network. I would call it a marketing opportunity, sales type of preferred provider network. And what I mean by that is, there's insurance companies now that are saying, "Hey, Moez, if you want to join our preferred list, we'll charge you $200 a month. And for $200 a month, you come on the top of our list and if patients come to us, we're going to recommend Moez' clinic."
So the advantage is that look, we're all in the space of social media, marketing, Google marketing, and Google ads and this is one other way of spending your marketing dollars and saying, "Okay, if I pay $200 a month to this insurance company, what's my return on investment? Am I going to get 10 new patients, 5 new patients?" From that point of view, it's a positive.
On the other side, it's negative because just because I paid $200 a month, doesn't give me anything better than Leslie, the chiropractor. It just means I've spent the money. So for the consumer, if he or she doesn't understand that they think Moez is a better chiropractor because he's on the top of the list, but really all Moez has done is paid for it. So it's a false sense of quality. Now, hopefully, Moez does a good job and he's providing excellent service, but it's buyer beware. So if you get somebody that spends a lot of money, but is providing poor quality care, they're still going to be on the top of the list. So there is that risk to the consumer of trying to select a facility or a clinic that they feel will meet their needs and their outcomes.
Do you envision sometime in the future, some safeguards coming in place to protect patients from this kind of thing?
Dr. Moez Rajwani:
I hope so. I think what we're seeing is insurance companies going into the business of health care. And I think this is another trend.
They're doing it in the pharmaceuticals. They're doing it in wellness. It's not uncommon now where there's even packages that the insurance companies offer: "Get your anxiety and stress for $500. Here's a six-week program."
So I think the trend, which is interesting is health and insurance not having that separation that they used to have and health care now being driven by insurance companies. And again, we've seen this across the board. Some of the stories we hear about how insurance manages health care. That's an American model, but you worry that something like that could happen (here).
We've traditionally been a publicly driven, government-driven model and now we've got insurance companies talking about health care, and I think that's something that we're going to have to be cautious of. And we're going to have to make sure that we're keeping our pulse on that.
Absolutely. Now, is there any other new business models that are coming up from insurers or anything that's changing in current models?
Dr. Moez Rajwani:
Traditionally, Leslie, insurance companies paid for the service irrespective as long as there was funding available. But all of the plans have something called “medically necessary” or in the auto insurance sector, it's “reasonable and necessary.” And I think insurance companies are now adjudicating more than they've ever adjudicated before.
So what I'm starting to think is going to happen is evidence-based practice, which we talk about. Evidence-informed practice that we talk about is now not only important from an outcome-driven point of view, which we've been emphasizing to all our colleagues about, "Let's provide evidence-based care because that's in the best interest of your patient." I believe that insurers are now going to be asking those evidence-based-related questions. So a patient comes in with back pain. What does the evidence say about back pain and is this chiropractor providing evidence-based care?
If, for example, with uncomplicated back pain, if they get a bill for x-rays, are they going to now ask the question? Well, the evidence says that if somebody comes with uncomplicated back pain who is 30 years old and has no leg symptoms, why would you be ordering an X-ray and should we be paying for that X-ray?
So I think we're going to start to see this notion of adjudication. Disability management is going to become a trend that we're going to start to see more and more in extended health care. We've always seen it in auto, wherein auto insurance there's been active adjudication about what's reasonable and necessary. I'm starting to see that in extended health care where insurers, because of cost containment are now wanting to make sure that the dollars spent are spent on evidence-based practice.
So this adjudication is that sort of the preface for an audit, or even if it's just one submission? Is an audit something different?
Dr. Moez Rajwani:
It's both. I think what we're seeing, Leslie, are two types of audits. We're seeing a "random audit," which says, "Oh, we want to check out the facility, make sure it meets all of our checklist and it's got enough space, it's got a waiting room, it's got closed offices," whatever looking for. And that the service that John received is exactly there. They have it available. They say that they use shockwave therapy and yes, they have a shockwave therapy unit in their clinics. So that's one type of audit. It's just kind of a checklist, no specification issue. Just want to make sure everything is aligned.
The second audit is where they see a trend in that clinic that concerns them. Maybe there's been a complaint from a patient, or they see a large number of billing numbers coming from that particular facility.
Now, it may just be they have high volume, but some of this AI-oriented technology data collection flags clinics. "Oh, why is this clinic putting 100 claims this month and last month they only did 20 claims? So what happened between last month and this? Something's going on in Moez's clinic." Now, Moez may have just had three new apartment buildings open across the street and now has more patients coming to him, or maybe there's something funny going on in Moez's clinic.
So audits are sometimes done on these types of cues that they get through their technology, or through a complaint, or repetitive complaints and it may be a specific practice that the chiropractor is doing or a perceived issue at the clinic, which may actually not be an issue.
Now, do they offset that AI with an environmental check themselves as to what's going on? I mean, you talk about the apartment buildings opening. I'm thinking if you're in a small community and there's a major car accident that happens on the highway nearby, and you have a lot of injuries coming out of that. Do they look at any of this external data as well, or not necessarily?
Dr. Moez Rajwani:
Leslie, I don't have insight in that. I'd love to know the answer to that question. I would hope that they do look at more than just a data point on a computer screen, but I have no idea.
Fair enough. So in these situations, how can a chiropractor best prepare for an audit or an adjudication from an insurance provider?
Dr. Moez Rajwani:
I think the best way first to manage an audit is before you ever get an audit, it's that whole prevention that we talk about with our patients.
So number one, we have college requirements and regulations and standards of care and practice, and we need to follow those. So the College of Chiropractors of Ontario comes out with a set of guidelines, whether it's on marketing, whether it's on what should be a proper assessment. And I think we have a responsibility and an accountability for our license to follow that. So that's our first level of protection that we're doing everything that our college is asking us to do, and we're doing it appropriately, whether that's a consent form, whether it's our office procedures, whatever that may be.
The second is to be, and I use this word loosely, but to have an ethical and value-based practice. We need to ensure that what we do in our practice meets that level of standard that ensures that we’re providing quality of care. We're providing cost-effective care and we're doing it with a set of ethical principles from which we work. We need to make sure that our billing practices, the way we market ourselves, the services we say we do are actually what we are doing.
And I think it's really important. And for each person that's maybe slightly different and I'm not here to judge what I'm saying, that we need to be able to do that we need to ensure that that experience for that patient coming into our office is of the highest ethical standard so that if we do get audited, we are an open book. We are able to show what we do, and we're able to do it in a way that the insurance company looks at it and says, "I'm not sure why I came here because there's nothing here to see."
Now, if you're getting an audit, I think that's a whole different question and we're actually working on an audit tool. But if you're going to get an audit, then you need to make sure that you're prepared for the audit.
So if it's audit of a specific case, make sure you know that case, make sure you read your clinical notes and records, make sure you understand your office procedures. Answers like, "I didn't do that. That was my front desk staff," is not a good answer. As the primary chiropractor in that office, you're ultimately responsible for your staff. So know what your staff does.
I know it's busy and sometimes we don't know what happens in the front desk and I can be guilty of that too, but we need to know how they're dealing with the patients, how they're accepting payment, what are they doing if you're giving a reduced rate or something like that for compassionate grounds or because the patient can't afford it, write it down, put it in your notes.
Tell them why Moez is getting $50 a visit and Leslie's is only $35. Why is there a difference? Well, because Leslie, in this case has just lost her job. She needs the care and we've come to an agreement that you can afford $35. It's okay to do that. And it's great value that you do that, but you have to write that down because from an insurance perspective, they don't understand why one patient is getting $50 fee and one person's getting a $35 fee. So write it down in your notes. Be able to show the auditor that, "Look, there's a reason Leslie's only getting charged $35." So these types of things is what I would say you need to do to prepare for an audit.
Now, you mentioned an audit tool that you're in process of developing. Can you give us any kind of an advanced glimpse on what that might look like?
Dr. Moez Rajwani:
Sure. So the Extended Health Care Advisory Committee (Council) that you talked about at the beginning of this, we had a few goals that we wanted to set out for our outcomes at the end of our two-year term.
The first of course is the E-H-C guide. And I hope that chiropractors use that and learn from it. And please give us feedback on how we can make it better.
The second is this audit tool. So we're working with a couple of chiropractors and others that have had audit experience. Either they may have done audits or they've had their clinic audited, and they've been very fair and open to us and say, "Look, I want to share with my colleagues in a private and confidential way how I can help them. So if they ever get audited, what can I do for them?" So with that and the advisory team, we're in the process of creating a tool. When that tool comes out, it'll be like a checklist of questions that you can ask yourself and your staff can ask as you prepare for your audit.
Great. Well, look forward to hearing about that. Would you say audits are on the rise?
Dr. Moez Rajwani:
Cost containment is on the rise. Audits will be on the rise. I think unfortunately that microscopic look at what we're doing in our practices is not something that's going to go away. I think we're going to continue to see these types of things from third-party payers.
Now, is this an isolated case that's specific to chiropractors? Are insurance companies unfairly targeting chiropractors these days?
Dr. Moez Rajwani:
We started doing some inter collaboration with other health care professional associations, and I know that other organizations are also dealing with similar types of queries, similar types of questions. So, no, it's not only chiropractors that are getting audited. I think other regulated health professionals are also getting audited.
Thank you, Dr. Rajwani for sharing your insights on E-H-C today and what O-C-A members can do to keep up with these trends and work effectively with insurers across Ontario.
In part two of this series, which drops on October 15th, Dr. Rajwani will return to discuss the rise of virtual care or telehealth and how insurers are addressing it, as well as other changes that have been shaped by the pandemic.
I hope you'll join us.