I started practicing in 1986. Insurance companies paid my bills on time and in full. The occasional delay or denial was usually resolved rapidly. I treated them fairly, and they reciprocated. That year, I went to my first (and last) big chiropractic practice-building seminar. It was three days long, and filled with the most mindless, embarrassing, patronizing dogma I had ever heard. One practice builder told us, "They come in hurt; you treat them 10 times over the course of a month; they get better; and now they're walking out of your office. What are you going to say when a patient with 30 visits in 11 months is leaving your office?" Needless to say, asking the patient to call when he or she (or someone else) needed me was not what the practice builder wanted to hear. At this seminar, the lowest form of life was a "pain doctor" (yours truly). It was my initial exposure to the wellness concept and the techniques some presenters taught to "capture" those unused visits. I thought then, and still do, that billing insurance for this type of "treatment" was unfair, wrong and something I would never do.
After writing last year's "Food for Thought" article, "How to Pick a Chiropractor" [www.chiroweb.com/archives/20/03/01.html], many of the hundreds of e-mail messages I received contained statements of the ilk, "I know you are receiving tons of hate mail, so I thought I'd just write to let you know I agree with you...." It may come as great surprise to many of those who wrote (both pro and con) that 50 percent of the responses I received were positive. This brings me to this year's topic.
Memo to the Insurance Industry
To insurance companies: There are plenty of chiropractors who do not overtreat, overutilize or overbill. We dislike chiropractors who do this as much as you dislike them. I personally applaud all the tactics you use to make their lives difficult, and I am guessing many of those chiropractors who agree with my ideas feel the same. However, you harm yourselves, your policy-holders, and the wrong chiropractors by assuming everyone is out to get you. You (the insurance industry) should do everything you can to treat legitimate chiropractors and their patients fairly. You know who they are, because you have their practice profiles, and in the cases where a profile is out of the norm, you know how to investigate whether the practitioner is legitimate or not.
The following is an example that could undoubtedly be multiplied many hundreds of times by many chiropractors: Last year, a patient entered my office who had been injured in an automobile accident. He was treated on five occasions, and responded quite favorably. He was released with a total bill of $580, yet the insurance company did not pay my bill. My office made numerous calls, and sent eight statements. Finally, after four months, we received a check for $360. My office manager called and was told we overcharged the insurance company. (As an aside, she will often tell her family, friends and patients, "Before I started working for Dr. Andersen, I had no idea how poorly insurance companies treat doctors.") I then had my receptionist call; wait through the voicemail; deal with the screeners; and finally get a supervisor on the phone. At this point, I picked up the phone. Here's our conversation:
Dr. Andersen (DA): Do you think many chiropractors treat people too long?
Insurance Company (IC): Yes.
DA: Do you think many chiropractors treat people too many times?
DA: Do you think many chiropractors charge too much?
IC: Sir, what is this? Sir, please get to your point.
DA: In how many 30-mile-per-hour rear-end accidents into a stationary vehicle will all injuries resolve in under 30 days?
IC: Aaaah...not many.
DA: How many moderate-impact cases resolve with less than 10 treatments?
IC: Not many.
DA: How often is a bill for this type of accident less than $600?
DA: Then why are you punishing me for resolving an injury in less than 30 days, with fewer than 10 treatments, for a fee of less than $600?
IC: Your charges exceeded "usual and customary."
DA: What is "usual and customary?"
IC: That is information we cannot disclose.
DA: Then I must ask you, what do you want? You just complained about excessive treatments and excessive billing when I got a patient better for under $600, and you still want to treat me like a criminal and punish me. The patient got well because:
- he was highly motivated; and
- he received quality treatment, including substantial soft tissue work.
What would you have wanted me to do - give you a "usual and customary" charge of $50 (?) for a "pop-and-go" and treat him 25 times? I get the feeling you think either:
- every patient magnifies his or her symptoms; or
- every bill - large or small - is padded.
DA: Well, I sure hope this call is recorded for "quality control!" For everyone who is listening, I don't like dishonest patients any more than you do. But the good news is that your industry has made this whole process so miserable, most insurance patients I see wait too long to start care because they don't want the stress you cause.
IC: (long pause)
DA: I do not understand why, when someone does a good job, we still get penalized. I did $580 worth of work, and I expect to get $580 worth of reimbursement. Do you expect me to charge $50 for a $100 treatment?
IC: (long pause)
DA: Why won't you just look at the bottom line - which is a much smaller bill with far fewer visits than your statistics dictate for an accident of this type - and realize that you are upsetting an honest patient and a good chiropractor?
Five months after the patient was released, the company agreed to pay my bill in full. My question to the insurance industry: How much interest income do you make each year by stalling on almost every bill you pay?
Here is another example (I have so many, it's difficult to choose just a few): A woman with neck pain entered my office for treatment and examination. We called the company for whom we were a provider (membership on its panel included a reduced fee schedule) to confirm benefits. One of the questions my staff asked was "Would X-rays be covered?" The company's answer was "Yes." I then examined the patient and told her, based on my findings, I thought we should be able to resolve her problem in less than five visits. I also told her I was not going to X-ray her unless her response proved unsatisfactory.
The patient appreciated my attempt to save her the exposure to radiation. (I also felt the insurance company would appreciate my attempt to save them the cost of X-rays.) After four visits, her improvement was only 20 percent, so I took AP and lateral cervical X-rays. (Her problem area was C6-C7.) We saw some degenerative joint disease (DJD) at C6-C7, which explained the slow response. After six additional visits, she was released "permanent and stationary," with full resolution of pain. Our bill was submitted to the insurance company and rejected; the reason: Our X-rays were unauthorized.
We resubmitted the bill, informing the insurance company representatives we were told we could X-ray. They gave us a second denial, saying we were told we could X-ray on the first visit, but since we did not do so, we had forfeited our authorization to X-ray at a later time. After a flurry of phone calls, we submitted another appeal. This time, we were rejected because we did not take enough X-rays. The rejection letter stated that if we were going to take X-rays of the cervical spine, we should have taken at least three views. When my staff showed me this rejection letter, you can imagine my reaction!
We made some phone calls and got through to a supervisor, who transferred me to a staff doctor. I told him my story - how I was trying to save the patient exposure to radiation, and save the insurance company the cost of X-rays. He began to read me some rules about the amount of views required. I continued to argue with him, after which he stated I should write a formal appeal report. I spent the next hour writing the report; we submitted it and - lo and behold - six weeks later, I finally got paid. All told, it was six months before I received payment for an examination, two cervical X-rays, and nine treatments, totaling $300. I refused to renew my policy with this company shortly thereafter. When asked why, I stated that working for substantially reduced fees was already a sacrifice, and I simply could not afford to spend the additional time and money required on every single case of every single policy-holder to collect the money I earned months ago. I told the company if I had seen this patient 56 times for her symptom complex, that would be one thing, but it was unacceptable to be "jerked around" for months on straightforward cases.
Currently, it takes more labor; phone calls; paperwork; resubmissions; and appeals to collect smaller reimbursements from the insurance industry. No one likes to be voice-mailed, "fine-printed," stalled, delayed and treated unfairly. I realize that the insurance industry has more money and more power than the health care industry, and I realize we cannot compete with the money you donate to our elected officials. However, it is this author's opinion that the insurance industry should take a close look at how it does business. Treating honest patients and doctors like thieves increases both animosity and anger. It creates an environment that breeds contempt and causes everyone to have a "get-even" attitude toward your industry.
Finally, when patients see their premiums continue to rise, and doctors see their reimbursements continue to decline, do you think we believe you when you complain about the increasing cost of chiropractic care? What do you think we say when you cry "poor," yet your profits and reserves indicate the opposite? What would you do if you were a chiropractor (or patient) and the insurance industry treated you like you treat us?
Many patients and many chiropractors are trying to do the right thing. It would be nice to see the insurance industry reserve its "usual and customary" treatment for those who deserve it.
A Final Thought
Imagine you go to the local market, buy a bunch of groceries, then tell the clerk you will pay what you want, when you feel like it. Payment will probably be less than the bill. You mention that he or she may need to call, write, fax and e-mail over the next few months, or you will forget to send the reduced check (without interest) altogether. Is that fair?
G. Douglas Andersen, DC, DACBSP, CCN
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