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Chiropractic in Workers' Compensation -- A Search for AnswersBy John Gantner Q: Workers' compensation cases are an important part of every chiropractic practice.A: Not true. In many states chiropractors see few if any workers' compensation patients. A review of the history reveals that in recent years a few states (like Oregon and Florida) have sharply curtailed chiropractic participation in their workers' compensation programs. New Jersey and several other states, due to a provision in their law that gives the employer the sole right to decide on the treating doctor, have effectively reduced or shut out chiropractic treatment. What makes these developments most disconcerting is that these changes have been made at the same time that respected studies (Manga, Manga II, Meade et al.) show chiropractic to be more cost effective than ordinary medical care. It is safe to say that every element of chiropractic participation in workers' compensation varies greatly between the states. Fees, requirements to appear at court, controversy and administrative delay show wide variations. Nobody has ever tried to get a grip on the often severe statewide differences in chiropractic participation in workers' compensation cases. I have received conflicting reports on how the workers' compensation system works from several doctors practicing in the same state.This article is an effort to gather accurate information about chiropractic participation in all the states. Once we learn just how it is in various states we may be able to come up with some reasonable strategies to improve things. Dynamic Chiropractic has been kind enough to participate in this project. With your assistance we can all learn a great deal. In some states, such as New York, there is an enormous amount of controversy and fairly liberal use of chiropractic consultants who almost routinely find the claimant to be at MMI. In other states there is little controversy and minimal use of consultants. Some states use "scheduled" fees for chiropractic services, while others allow usual and customary fees. I am told that in Nevada a DC must report and re-examine every six visits, and that a claimant must get an attorney if further treatment is disapproved. In Virginia, it is my understanding that a chiropractic panel must approve before a claimant can see a given chiropractor. (Do they do that for medical treatment too?) By contrast, Wisconsin has an excellent program with few problems regarding chiropractic treatment. When the Australian workers' compensation system was undergoing fundamental restructuring, it studied various elements of Wisconsin's smooth operating workers' compensation program. In some states, DCs are paid a certain fee for an adjustment with additional fees paid for one or two modalities. In other states chiropractic service is "global" and covered under a single office visit fee. In some states chiropractors are paid usual and customary fees for workers' compensation cases; in other states there is a set fee schedule. In New York, the fees are set differently for each of four different areas of the state. Doctors practicing in some states are increasingly driven to produce more reports and more paperwork to satisfy carrier's demands before the check comes. In New York, even after a court rules that a doctor should be paid, the carrier can appeal the decision and hold up payment for treatment for many more months. And even when the carrier's appeal fails, another obstacle (arbitration) is put in the way of payment. This forces the treating chiropractor to take anywhere from several hours to a full day away from the office to attend an arbitration hearing to justify once again the right to the fees due in the case. Between court hearings, appeals and the arbitration hearing, a simple workers' compensation case in New York can take more than a year to resolve. And even after that, the doctor may have to appeal to the state insurance department for assistance in getting payment for services. Certain 1996 changes in the disputed bill process are so complex that many doctors are still forfeiting legitimate fees because they do not understand the process involved and/or the use of the new forms. Why is there so much controversy with chiropractic cases in some states and not much in others? One can only venture a guess at this point. We seek to answer that question by soliciting information from doctors working in the trenches of workers' compensation. If you practice in a state with a reasonable chiropractic environment for workers' compensation cases, your responses to the few questions that appear at the end of this article will be of great help. In like manner, if your state has a great deal of trouble with chiropractic in workers' compensation cases, it will pay to understand each element of those problems. We see instances in which the chiropractor's opinion regarding disability is honored completely, and others in which it is not allowed. In some states managed care has made great inroads into workers' compensation cases; in others it is still a rarity. It would help to know which states are heavily into managed care and how it is working. The Washington State Court of Appeals recently issued a ruling which grants the insurers the right to sue chiropractors who submit phony billings on behalf of insureds. In its own way this ruling infers that DCs reporting is less credible than other doctors. What do they do with MDs who submit phony billings? Based on my limited study, it is clear that enormous differences exist in the chiropractic element of workers' compensation in various states. And it appears that the screws are gradually being tightened ever further on chiropractic participation. This may come about quietly in each state, but it is a very deliberate process. As far back as 1990, the president of Liberty Mutual Insurance, Mr. Countryman, convened a high level meeting of insurers, business and labor officials to discus the "crisis" in workers' compensation. Among other things, this panel discussed chiropractic as a "problem." In spite of this clear warning there has been no concerted effort in our profession to change that attitude. There should be. That is our mission. Our failure to come to grips with the problems we face in the workers' compensation arena will allow these attitudes to harden further. There is no national clearinghouse for information regarding chiropractic participation in various state workers' compensation programs. There should be: without it we stand to lose even more ground. If the best defense is a good offense, then we should be taking time now to study chiropractic services in workers' compensation in each of the states. Please take a few minutes to answer these questions. Cut the questionnaire out or make a copy and return it to me at the address below. You can fax the completed form to me at 716-798-0342. If you wish you can answer with additional commentary via email to
Doctor, May I solicit your assistance in gathering this information? Together we can learn a great deal. All that will be necessary is for you to answer the questions above and mail them in to me at the following address: Dr. John Gantner email:
While you are writing, feel free to add any additional information that you feel might be of help. It would help a great deal if you supplied your email address. References
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