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Dynamic Chiropractic – November 17, 1997, Vol. 15, Issue 24

Utilization Review: How to Win the Insurance Game

By Steve Freeman, DC
Your face turns from pleasure to scorn as the check you expected to pull from the insurance envelope turns out to be not a reimbursement, but a notice. "We (the insurance carrier) hereby request a utilization review to determine the reasonableness and necessity of chiropractic care ..." Any doctor in practice for a length of time will have received that notice, and if you're anything like me, you are privately annoyed that someone else will be judging your professional opinion.

As a chiropractor providing peer reviews, let me assure you that it's nothing personal. From the insurance industry's standpoint, it's merely a means to an end; question enough doctors and eventually you will find someone providing improper treatment. In the quest to "manage care," insurance companies are now becoming faster at ordering independent reviews to determine necessity.

To the surprise of many chiropractic providers, there is no incentive for chiropractic reviewers to deny claims. When I was approached to perform peer reviews, I was specifically told to provide honest opinions that I felt conformed to reasonable practice parameters. I would therefore like to offer my colleagues an idea of what is looked for in the process of utilization review, so that they can continue to perform the same outstanding care and get paid for it.

(1) Chiropractic documentation is notoriously poor. Understand that in most states documentation to fulfill proper practice parameters require a thorough history, examination, diagnosis, and treatment plan to be present in the patient's record. Often, cases with a good intent lack this vital information. It is impossible from a reviewer's standpoint to agree that a patient requires extended periods of care (or any care, for that matter) when this information is absent from the record. So do yourself a favor. If your treatment records currently do not contain this documentation, include it from now on.

a. Treatment notes that are in travel card format or are handwritten make your case that much worse. There is an inherent initial impression made when pulling a file from an envelope. If a reviewer knows that he will have to work very hard at reading scribbles on a page, he may be inclined to give you a hard time. By the same token, travel cards immediately give a sense that the doctor is just flying room to room, and probably doesn't take time to keep good tabs on his patient. If at all possible, have your treatment notes typewritten, but not "canned." If this is not practical, then take the time to notate exactly what is going on with the patient.

b. Remember that the patient file is supposed to be a "story" of the patient's care, legible and intelligible to anyone reading it. Pull out one of your files and pretend you know nothing about the patient. Would you be able to figure out from your notes what was going on with the patient? Could you tell what the plan was, both now and down the road? What did the x-rays show? Why did you recommend a neurological consultation? If you can't figure it out, neither can a reviewer.

(2) When DCs refer out for diagnostic testing, they customarily receive a written report which is then entered into the patient's file. However, because chiropractors often take their own x-rays, a report is seldom included. While it is not necessary to type out your own reports, there must be some indication of the x-ray results in the patient's record. A typical problem occurs when a doctor states in a review that, due to biomechanical changes in the cervical spine (such as a cervical kyphosis), extended care is required. However, in looking through the patient file, there is no reflection that a cervical kyphosis is present. Just because you have it on film doesn't mean it exists. It must be in the patient's record.

Which brings up a related point. You are responsible for reviewing the patient's past medical history, no matter how unrelated to chiropractic practice. Get this information! Have you patients sign a medical release, then call all the treating doctors and have them send you their records. Get a fax machine. Most offices will you fax you pertinent records within a short amount of time. Case in point: young male with history of surgically-induced short leg goes to the MD and is relieved of low back pain by a heel lift. Two years later, he presents to a chiropractor for care. This DC recommended long-term supportive care, without ever receiving information that a heel lift had solved the problem in the past. Result? Denial of claim.

(3) Practice parameters agree that if a patient has not responded to your care within a certain time, either of two things must happen: a referral should be issued or further diagnostic testing should be ordered. The vast majority of chiropractic patients begin seeing some relief within 2-4 weeks. Therefore, if there is no change, be proactive and do what is necessary: alter your treatment and begin again. Understand that if after several weeks no change is seen, your care is no longer indicated! Think about it. If you were seeing a doctor whose treatment wasn't working in a reasonable period of time, would you continue to go?

Make the appropriate referrals once you've decided that the patient doesn't seem to be responding. Refer to a chiropractic specialists: they're held in as much esteem as medical specialists.

What is a reasonable time prior to referral? Only you can answer that, but the current standard lies somewhere between two and six weeks, depending on the parameters used by the reviewing doctor. Build your case by presenting reasons why the patient is taking longer than usual to respond.

(4) Once a patient has been seen for a period of time, it is considered customary to begin tapering off treatment, with the goal being patient discharge. Recognize that in many cases workers' compensation and motor vehicle insurances reimburse only up to the point of maximum improvement, not up to when the patient completely feels better. This is a big distinction. A patient may continue to have significant pain, but be at maximum improvement. To justify ongoing, supportive care, you need to document that the patient's status will deteriorate without your care, then you must prove this through a clinical withdrawal from care. Document this. If the patient gets worse, then re-institute care and document this fact in the file.

These last two points bring up a recommendation. Get yourself a copy of the Mercy document (Guidelines for Chiropractic Quality Assurance and Practice Parameters). Most reviewers are using this as basic guidelines for practice parameters. Most importantly, read pages 124-125, which covers supportive care and length of treatment. You should be familiar with these, so that you can incorporate them into your patient management.

(5) If you lose your initial review, request a reconsideration if it is available. Many insurance companies know that if they get an initial denial, many doctors will not pursue it. Along the same lines, request a telephone conversation with the reviewing doctor. Plan ahead about what you will say, and justify your care! Be specific! This is your patient, and you know him better than anyone else! The reviewing doctor is going to ask for certain things: current state of the patient; where care is heading; if the patient is getting better; if discharge is in sight; have there been any referrals, etc. Be prepared for these. Be specific about your care and your goals. Be able to justify why you did certain things.

As horrible as it sounds, if you have a problem justifying your treatment to a review doctor, you simply must review your practice procedures. I understand the chiropractic philosophy, but in all honesty, motor vehicle and workers' compensation carriers couldn't care a lick about your philosophy. You must conform to certain health care guidelines if you're going to participate in them. So if you lose a review, see what you did wrong and correct it.

(6) It is my opinion that every doctor, no matter how regimented in his treatment or documentation, eventually loses a utilization review. Sometimes it can just be a matter of differences of opinion, or maybe the reviewer is having a bad day. Don't lose sight of the fact that differences of opinion are common in medicine and chiropractic. I think we all agree that, if someone is going to review our work (which all health professions put up with) we'd rather it be another DC than some MD or nurse. Bear with it, and always put yourself in the best possible position to win.

Steve Freeman, DC
Philadelphia, Pennsylvania


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