Using Guidelines to Justify the Need for Care
By Jay Greenstein, DC, CCSP, CGFI-L1, CKTP
As insurance chair for two state associations, I often get calls regarding reimbursement and medical-necessity challenges.A good friend of mine and chiropractic colleague, Tim, called me last week and said, "These managed care plans are driving me nuts! I have chronic patients and all the insurance companies want to do is limit their visits to six and done. What do I do?"
"Tim," I inquired, "Have you seen the new chronic pain guidelines put out by the CCGPP (Council on Chiropractic Guidelines and Practice Parameters)?"
"Dude," Tim continued, still irritated about insurance companies, "I can't even say those letters without being tongue-tied, let alone know where to find these guidelines you're babbling about."
"Do you want to get paid for the medically necessary services you're providing?" I asked, all the while knowing the answer.
"Of course I want to get paid," he said. "What do you think I am, a free clinic?"
"Then listen up bud. Here's what you (and every other DC out there) needs to know." I then went on to explain the following:
First, understand the clinical guidelines of the insurance companies you're dealing with. Most carriers have clinical algorithms (that are available online) that describe how they make decisions, including necessary steps to verifying medical necessity:
Second, understanding minimal clinically important change (MCIC) is crucial. MCIC is the smallest amount of change in a patient's condition that can be considered clinically meaningful and justify continued care under a treatment plan. For instance, how much should an Oswestry or NDI change in order for the improvement (and thus justification for ongoing care) to be considered meaningful? (The answer is five points). Algorithms aren't the most exciting thing to examine, but if you understand them, you're likely to deliver the care your patients need and subsequently get paid for it.
Third, you need to understand what the world of science recommends for the chronic patients you're treating.
"Tim, are you at your computer?" I asked. "Yes" he replied. "Good, go to www.ccgpp.org."
"C-C what?!" he exclaimed in frustration. "C-C-G-P-P," I said. "Just think of Chronic Condition Guide Patients Paid."
"Ah, just like back in chiro school ... makin' up names to remember stuff. OK, now what?"
"Click on 'Published Documents' and then click on 'Chronic Pain Guidelines,'" I said. "Look at Table 1. Did you know that chronic is considered anything over 16 weeks? That's four months. How many of these patients you're treating have had pain for more than four months?"
"A ton!" he exclaimed.
"Exactly. Now, how many have had more than three episodes?" I asked.
"C'mon, you're kidding me, right? Eighty percent of them!" he replied.
"OK, now look at Table 2. See how many complicating factors are listed? Do you document any of those in your notes or in your submission forms to the carriers?"
"Uh," he paused, "not always."
"Did you know that a moderate or severe exacerbation should be treated as an acute problem and would require, according to the literature, an initial course of care of three times per week for two to four weeks, and that recommendation is supported in the chronic spinal pain consensus report developed by the CCGPP?"
"I do now!"
"Tim, the CCGPP develops guidelines for a reason: to protect the patient and to allow individual doctors to implement a treatment plan that is based on what the patient needs, backed up by the science."
"Hmmm ... I always thought that guidelines were restrictive," he said.
"Guidelines need to be flexible and modified for what the patient truly needs," I replied. "But at least now you have scientific support for any insurance company that gives you the blanket statement that 'most patients get better in six visits, so why do you need more?'"
"Jay, this has helped a ton. I will definitely download the rest of these papers and use them to defend my patients' right to the care they need and deserve."
"Great, just remember, you need to understand the minimal clinically important change required by the carriers, document well and use the guidelines to support your treatment plan. If you do these things, you, and most importantly, your patients, will be good to go!"
Dr. Jay Greenstein, CEO of Sport and Spine Rehab and chiropractor for the NFL Washington Redskins cheerleading squad, currently serves on the CCGPP as communications chair. He is also insurance chairman and public-relations chairman for the Virginia Chiropractic Association, and insurance chairman for the Maryland Chiropractic Association.