I would like to respond to the recent letter from Dr. Gilles Beaumont of Mobile, Alabama concerning the Blue Cross and Blue Shield Service Benefit Plan for federal employees, retirees, and their families (see Dynamic Chiropractic, January 1, 2001, page 12, "PPO and HMO Membership - Lots of Promises, But Short on Delivery," or go to www.chiroweb.com/archives/19/01/18.html).I feel it's important to correct the record concerning coverage for chiropractors in this program.
The Service Benefit Plan does not routinely cover services billed by a chiropractor. However, in states designated by the U.S. Office of Personnel Management as medically underserved areas, we will cover chiropractors when they bill for covered services performed within the scope of their license. For 2001, 11 states have been designated as medically underserved. These are: Alabama; Idaho; Kentucky; Louisiana; Mississippi; Missouri; New Mexico; South Carolina; South Dakota; Utah; and Wyoming. Federal employees who receive covered services from chiropractors in those states will have benefits paid, and the amount of the benefit will be based on the contracting status of each provider with the local Blue Cross and Blue Shield Plan. For instance, in Alabama, Service Benefit Plan members enrolled in our most popular plan (the standard option) that see participating chiropractors will pay 25 percent of negotiated charges after the $250 calendar year deductible for medical services. If the member sees a chiropractor who is preferred or who does not participate with the Alabama Plan, reimbursement levels will differ. If Dr. Beaumont participates with the Alabama Blue Cross and Blue Shield Plan, and since Alabama is designated as a medically underserved area, our members who see him will be covered as described above.
Additionally, Blue Cross and Blue Shield have negotiated a contract with American Specialty Health (ASH) that is increasing the availability arrangement with ASH. Federal employees, retirees and their family members who are enrolled in the Blue Cross and Blue Shield Service Benefit Plan can receive chiropractic services at discounted rates throughout the United States. This allows greater access to these services for all of our members. In areas designated as medically underserved, the discounts under our new program with ASH are only effective when our normal benefits are exhausted. The initial reaction to this discounted program has been very positive. We are excited about our affiliation with ASH and we look forward to a close partnership to provide services that meet our members' health care needs.
Senior Vice President
Blue Cross and Blue Shield,
Federal Employee Program
Not Licensed in Oregon
In your article regarding Todd Gastaldo on Page 52 on the January 1, 2001 edition of Dynamic Chiropractic, you refer to him as an "Oregon chiropractor."
Gastaldo is not now nor has ever been licensed to practice chiropractic in Oregon.
Oregon Board of Chiropractic Examiners
Views from a Former Claims Reviewer
It was with great interest and a sense of nostalgia I read Clara Tobin's (MRI of America, Inc.) letter (see DC, December 14, 2000, page 12, "Son of Claims Review Saga"). In the late 1980s, I addressed what I perceived to be gross irregularities in the claims review process. My feelings were published in the September/October 1988 issue of Colorado Chiropractor ("Why Fuel the Fire"). A related article appeared in DC, June 1, 1989 ("The Insurance Ruse Continues"). Your editor's note at the conclusion of that article called for the development of standards of care and stated: "lf we don't create one (a standard of care) that encompasses the full spectrum of chiropractic care, the insurance companies will create one that is simple, precise and extremely limiting." This is an admonition of the advent of managed care!
As a reviewer with a national agency during that period, I had firsthand knowledge of how at least one reviewing agency functioned. I also had a platform from which to share that knowledge, and did so. My goal was to educate colleagues and staff members about reviewing, and about one particular reviewing agency and its impact on chiropractors and patients.
Ms. Tobin's letter reveals what appear to be positive changes in the reviewing process. At least, what she says about MRI gives that impression. Even so, her explanatory defense of MRI exemplifies the continued presence of unfairness such procedures provide. She admits these reviews are what have become known as "paper" reviews. Only under special circumstances do the reviewers contact the providers or make their identities known. I find nowhere in her letter where Ms. Tobin addresses correspondence or physical contact with the patient from the reviewer. How can fair reviews of the efficacy of treatment be performed without input from the principal parties of such reviews?
She admits to a "matched specialty" basis of review. This is the way it should be. Such has been the standard of most reviewing agencies for more than a decade. What she fails to provide is whether it is a requirement of the reviewer to be matched with and have equal training as the provider in every area of questioned procedure.
Ms. Tobin notes: "MRI's first responsibility is always to the patient, acting in our clients' best interest. This statement appears to be either totally ambiguous or an effort to perform the impossible task of serving two masters simultaneously: the patient and the client. Maybe I'm wrong. I have been under the impression that reviewing agencies are paid by their clients to perform services. The clients in this case are (according to Ms Tobin) "health insurance organizations, third-party payers, employers and directly for patients and providers." The service is to curtail cost proportionately enough to warrant the expense of hiring such an agency and still return a profit. The fact that Ms. Tobin can boast in excess of 600 clients is evidence that the company provides a satisfactory service! How is it possible to have as its first responsibility the patient while at the same time acting in its clients' own best interests by reducing or eliminating services felt essential to patients by doctors?
Ms Tobin defends anonymity of the reviewers, stating: "Anonymity is essential to protect the reviewer from possible repercussions in his or her practice due to the review of a colleague." If the reviewer is well credentialed (as Ms. Tobin says each must be) and can defend opinions rendered in any particular review, and is comfortable knowing MRI will support any legal challenges, what is the fear? I have wondered why busy doctors would place themselves in a position of possible repercussions. Is it possible the compensation outweighs the risk, so long as one remains anonymous? I would think that reviewers who feel they're doing their part to rid the profession of those who abuse the system would be proud to stand tall and speak out, letting those who would even chance such abuse know that reviewers are a force to be reckoned with! I did not agree with the policy of reviewer anonymity when I was a reviewer, and I still don't.
It may appear I am totally against claim reviews: quite the contrary. I am an advocate of claim reviews so long as such reviews are performed on a level playing field, and that the best interest of the patient is paramount. Rarely has such been the case in our profession. Never have I observed it when "for profit" reviewing agencies are involved.
There will always be providers who attempt to take advantage of the system. Abusers should be stopped and punished. Of course there have also been cases of abuse on the part of insurance companies and reviewing agencies as well (State Farm Insurance Company and Medical Claims Reviewing Service). This blatant abuse and fraud was exposed in a recent nationally televised investigative report.
Our goal should be to establish a fair and unbiased reviewing system that is not influenced by financial gain. In my opinion, abuse can be curtailed. If reviewing agencies and their clients are sincere in their desire to perform unbiased claim reviews, I would suggest these procedures:
- Establish a specific set of national standards for all reviewers to follow.
- Make known that which constitutes grounds for a review.
- Offer classes to the profession, paid by clients of reviewing services, and instruct providers on acceptable documentation protocols as well as "red flags" for possible review.
- Ensure the reviewing doctor has adequate training to address specific issues regarding incorporation of a questioned technique, diagnostic profile and/or modality under review.
- Have in force a "pre-review" system wherein the reviewing agency assures the requested review does have merit, thereby reducing the number of frivolous reviews.
- Inform the doctor to be reviewed such action is pending. List the reason(s), allowing ample time for the doctor to respond, and provide additional information to support his or her position.
- Eliminate anonymity of reviewers. Retain only those reviewers who are fully prepared to defend their position.
- Require an open dialogue between the reviewer and provider.
- Require reviewers to keep accurate notes on questionable aspects of a review, and to document input obtained from the provider regarding same.
- When effectiveness of treatment and need for further treatment is in question, obtain input from the patient.
- Record all conversations between reviewer, provider and patient.
- In case of appeal, provide a neutral arbitration panel whose decision shall be final.
I am not so naive as to believe all abuse and fraud will be eliminated. When money is involved, there exists the potential for abuse and fraud by providers and third-party payers. The suggestions I have provided are an attempt to balance the scales when reviews appear necessary.
I respect the comments of Ms. Tobin. I am certain she feels her company is providing a valuable and needed service. There is no question she feels MRI and its anonymous reviewers are doing an excellent job. However, there is no question that I view this subject from a completely different point of view.
I have practiced chiropractic for more than 35 years. I have functioned at many levels: as practitioner, teacher, speaker, writer, and yes, claims reviewer. I have one final comment for Ms. Tobin to ponder: You have come a long way and have understandable reason to be protective of assault. Unfortunately, you have a long way yet to travel before your company and those like it will be doing what is necessary to provide genuine, fair reviews on behalf of the most important person in the equation: the patient.