QuestionQUESTION: Hello,
I am a chiropractor that recently had a patient come into our office about back and neck pain. In the course of obtaining a history, I learned the patient had a car accident exactly eight months prior. After documenting her pain and performing objective tests I arrived at a few diagnosis and wrote down the codes.
The patient was asked who the insurance carrier was that was responsible for the bill. The patient, whom was under her parents insurance and driving their car thought it was insurance carrier A. After calling insurance carrier A, we found out it was not... so we asked the patient to ask her parents what insurance carrier they had.
After about two weeks, the patient finally came in with the correct insurance carrier's information and our office made contact with them. The patient found the information on the bill paid by the insurance company to the ER in the hospital the patient saw the day of the accident. Coincidentally, three out of my four diagnosis codes matched from the ER's records.
Now, about a month after this patient has been treated, I've received two pieces of certified mail letting me know this case will be reviewed by a contracted "disability management consultant" company.
I am a relatively new chiropractor... I've got about 18 months under my belt. While I don't have a doubt that this patient's injuries stem from the accident (prolonged muscle tightness/spasms and neck/back pain), I'm fearful the reviewing chiropractor will do whatever it takes to find the care is "not medically necessary". My wife, also a new chiropractor has been questioned about another case, and the chiropractor badgered her about why she didn't do a test a certain way.
The way I look at it, this shouldn't be about whether I did a certain orthopedic test the same way they would have... but whether or not the patient's pain/symptoms are consistent with the pain she experienced immediately after the accident.
After asked a 2nd time why the patient didn't seek care before 8 months had elapsed, she simply stated she didn't want her parents insurance rates to go up, so she dealt with the pain. Little did she know that the rates will not go up in regards to her seeking medical care. By the way, the accident occurred in the state of PA... a no-fault state (and she was at fault).
After receiving the certified mail, I contacted the claim adjuster as I wanted to get a little information on why the review is being done. I asked if it was because there was an eight month gap from accident to walking in our door and he said no. I told him I figured that was the reason, because we've had several MVA patients in our office, and haven't had a review yet. The claim adjuster, with a very arrogant attitude, said I was making assumptions as to why the review was being conducted. He said that he was the one that initiated the review as it was called for. He then went against his own words and admitted the eight month gap was one of the reasons.
I then asked him if he had talked with the patient about her case and he said no. (I had asked her that day if anyone had contacted her from the insurance company, and she said yes, last week.) A minute later he then admitted to talking with her. He said that after talking with her, he felt a review was in order.
What bothers me about this:
The reviewer is paid by the insurance company... which is basically like the home team asking itself if it wants to make a payment or not. The contracted reviewer is there for a reason... to save the insurance company money. Am I right in feeling that some how, some way our claim will be denied?
If I'm paying some 3rd party to save me money, I'd expect results, otherwise I'd want another company in there doing the job.
But I guess I should have comfort in knowing that even IF they find against me, that I can still appeal the verdict, just so they can look at it a 2nd time and shoot it down.
I'm not saying a company shouldn't have the right to protect itself against false claims. I'm just leery that no matter what we do, this reviewing doctor will find something to poke holes at and say treatment is not medically necessary.
What I do know is... the patient came to me with moderate pain that had become increasingly worse over the last few months. That the pain is affecting her daily activities/work. That the treatment I rendered her significantly helped her and that when I lowered her treatment from three times per week to two she had a flair-up.. so we went back to three. To date, she's been in approx 16 times and feels significantly better, though the pain and muscle tightness returns without treatment.
Any suggests? Thank you in advance for your consideration on this matter.
Dr. E
ANSWER: Hi Dr. E.
Your fears, concerns and suspicions are well founded. The purpose of the review is to poke holes in your diagnosis, testing, treatment and prognosis. In addition, they are seeing to find issue with the delay in treatment.
Even though you are fairly new in practice it's apparent that you (either through training or experience) already know that the insurance company will do everything they can to reduce or delay any and all medical bills. The auto insurance industry still views Chiropractic as being akin to witchcraft. Unfortunately, the only thing you can do is to do your job to the best of your ability, but understand that very often your bills will be reduced. Always remember that it's not paranoia when they are really out to get ya!
I hope this helps
Richard Hixenbaugh
---------- FOLLOW-UP ----------
QUESTION: Mr. Hixenbaugh,
Thank you for your response, glad to know I'm not paranoid.
I have an important follow up question regarding response to the review of the claim. The reviewing company is asking me if I desire the reviewing doctor to contact me via a phone call.
I'm leaning towards checking NO, not because I'm making this claim up, but simply because of the experience my wife had in talking with one of them on the phone. The issue here should not be why I did or did not do an orthopedic test a certain way... but if the patient is injured as a result of the accident.
I'm leaning towards writing a letter explaining the patient's fears about her parents insurance rates increasing if she sought medical/chiropractic care. Then, as the pain increased it got to a point where she decided she had to do something as she started calling off work.
I am not the typical, quick working chiropractor. While I only have 18 months experience, I have always believed in a moderate amount of muscle work. A reverse in the cervical curve, often is the result of whiplash or prolonged muscle tightness. There is no way around it, it very often takes many treatments to overcome muscle tightness that's in spasm mode. The alternative is to see an MD that will give you pain relievers and muscle relaxers, which often cause other issues which can be severe.
So, do I allow the reviewing doctor to bombard me with what I should have done in his/her eyes during my exam, or do write a letter answering as many questions ask I can think of relative to the case?
If I go through this process, and they do deny coverage and then deny an appeal could I bring this case in front of the insurance commissioner? I feel this treatment is necessary, regardless if this insurance company doesn't want to pay the bill.
One last note: The parents of the patient no longer has insurance coverage with this company, which to me adds to the likely hood of a non-payment in this case. Am I crazy?
Thank you again,
Dr. E
AnswerHi Dr. E,
I'll answer backwards.
The insuewas in force at the time of the accident which is all that matters.
You could file (or actually it would have to be the insured and/or injured party) a complaint with the insurance commissioner, however don't expect much to happen. Most state insurance commissioners offices are bought and paid for by the insurance industry. In addition, they generally only get involved when an insurance law is being broken or the wording of the policy is nt being met. Issues of amounts payable, liability, negligence, treatment types, etc. are outside the purview of that office and are generally a matter for the courts.
I think you do anything and everything you can do defend your position. It may require a bit of work now, but, once you show them that you are willing to do what is necessary to defent your treatment and your patients claims, it will get easier to get them to pay you. You should save any and all correspondence so that you can call upon it again in the future.
You may decide to call the DR but you should also have your written letter ready to send as well. Be sure you say essentially the same thing in both formats. Then you just have to wait for the outcome. Good Luck!
I hope this helps
Richard Hixenbuagh
