As an instructor of advanced diagnostic methodologies my telephone and fax have been working overtime the past few weeks, and overtime is a gross understatement.
The polarizing effect of the Mercy Guidelines are not unlike the effect of aligning in the straight or mixer camp, and I think that misinformation and complications of the English language are the principle culprits.
Let me explain my own dilemma with these phone calls and faxes and what I have been able to learn as a result. Doctors are highly concerned because insurance carriers are denying chiropractic procedures nearly across the board based on Mercy.
I have received from prominent educators in our field, numerous faxes relating to carriers denying payment for everything from plain film radiographs, EMGs, digital x-ray analysis, to denying treatment for more than two weeks.
Of course, any rational practitioner who cares about the health of a patient should be up in arms. The blame falls on Mercy and possibly for the wrong reasons. As in any debate or war, semantics are very often at the root of the problem. Let me elucidate with some examples of over reaction that I have been confronted with, and how emotional these issues have become.
The rating system used by the Mercy participants placed emphasis on procedures utilizing the following scale:
Established
Promising
Equivocal
Investigational
Doubtful
Inappropriate
According to the Mercy Guidelines, "The first three ratings are positive, supporting use and reimbursement in clinical practice." (emphasis added) Well then, what's the problem?
Semantics and terminology is the problem. Most insurance policies do not provide coverage for procedures which are not accepted or "established." Procedures which do not fit the "established" criteria are considered investigational, a term also used my Mercy.
Carriers, therefore, are inappropriately denying procedures paraphrasing the Mercy document "out of context," making those who participated in the Mercy Conference the architects of the destruction of chiropractic in the minds of those doctors who are seeing their practices fall apart. Their concerns are real, but putting blame on the Mercy Conference is not the solution.
Another example comes from dozens of telephone calls concerning the imaginary "two week cap on treatment." There is no such animal in the Mercy Guidelines. The Mercy document states, "Up to a maximum of 'two' trial therapy series of manual procedures lasting up to 'two' weeks each (four weeks total), following which manual procedures may no longer be appropriate in the absence of significant documented improvement." (emphasis added)
What's wrong with that? Think of your state workers' compensation guidelines, fee facts, and other sources. Four weeks of treatment is a lot of treatment. How many of you actually get no results in four weeks of treatment? The key here is objective factual documentation of improvement or lack of same. Digital x-ray analysis, paraspinal EMG, and neurometer sensory nerve testing are the tools I've been teaching for the past four years for this very reason. Validation of the detection and correcting of the vertebral subluxation complex and its resulting devastating effect on the human body.
If you can "document" improvement, you are not going to have your patients' necessary treatment denied. Our profession must become "technically certain" about what it does to the standards of the scientific community. A Supreme Court case ruling comes to mind.
If a physician as an aid to his diagnosis, in effect his judgment, does not avail himself of the scientific means and facilities open to him for the collection of the best (court emphasis) factual data upon which to arrive at his diagnosis, the result is not an error in judgment but negligence in failing to secure an adequate factual basis upon which to support the diagnosis or judgment. (Supreme Court of Penn., October 9, 1963, 194 A.2d 167.)
We cannot allow the insurance industry to bastardize the Mercy Guideline. We can also not afford the luxury of commenting or detracting from these guidelines without benefit of having read them and having understood their content.
It is also appropriate for those who participated in the Mercy Conference to swiftly and vigorously confront inappropriate interpretations of the guides, which is already manifesting throughout the nation.
The Delphi process is one of the best mechanisms we have today for this type of consensus opinion. The Mercy Guidelines are a basis for further and continued work in this process, not the sole and final result.
I encourage all doctors of chiropractic to keep a civil tongue and an educated opinion based on the facts, not the conjecture surrounding these guides. It is the duty of every doctor in this nation to analyze carefully, comment factually, and recommend with an educated platform those issues which are of concern to him.
William Cockburn, D.C.
Austin, Texas
Editor's Note: Dr. Cockburn has been a licensed chiropractor since 1975 and has completed postgraduate studies at the Los Angeles College of Law. Dr. Cockburn has lectured internationally on "Factual Documentation of Soft Tissue Trauma," and maintains a consulting business in Austin, Texas.
For comments, you may reach Dr. Cockburn at:
Tele: (512) 288-0038
Fax: (512) 288-7779
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