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Dynamic Chiropractic – January 29, 2009, Vol. 27, Issue 03

How You Start Is How You Finish

By K. Jeffrey Miller, DC, MBA

One of the most important steps in receiving reimbursement for chiropractic care is billing the appropriate insurance carrier. Patients often have more than one source of coverage, and the carriers must be billed in the proper order.

Insurance regulations and policies mandate the order and degree of responsibility for every carrier involved in a claim. You must start well to finish well. To do that, your practice personnel must be familiar with the rules of order and must know the right questions to ask the patient to determine that order.

With the wide variety of available policies in today's health care market, this can seem like a daunting task. Employee benefit, workers' compensation, automobile, Medicare, Medicaid, home liability, business liability, disability and supplemental policies can all come into play when billing for chiropractic care. There are a large number of combinations possible when a patient has coverage from multiple policies. The policies may line up two or three deep.

A basic rule for the "batting order" is that policies rotate depending upon the location, situation and activity of the insured. In most situations, these factors establish responsibility and order for the carriers. This is important to the carriers, as insurance companies do not want to provide reimbursement for care unless it is their primary responsibility or until other carriers ahead of them have paid their respective portion. Order is important to the health care provider in establishing correct reimbursement.

Take Sally, for example. Sally is a 42-year-old secretary at a local insurance office. She has insurance coverage through her employee benefits package and is covered by her husband's employee benefit insurance. She also has automobile insurance and workers' compensation insurance. Sally's coverage from these policies is as follows during her day [see table].

Location, Situation, Activity Order of Coverage
Sally wakes to get ready for work Her employee insurance is first followed by her husband's employee insurance. In the case of an accident at home, Sally's homeowner's insurance may become first with her insurance moving to second and her husband's moving to third.
Sally drives to work Her automobile coverage is first followed by her employee benefit coverage. Her husband's coverage is third.
Sally arrives and begins work Worker's compensation coverage becomes primary, Sally's employee benefits are second and her husband's coverage is third.
Sally uses a company car to drive to the bank and make a company deposit Worker's compensation remains first followed now by the automobile policy that covers the company car (another policy snuck in here). Sally's employee benefit policy and her husband's employee benefit policies move to third and fourth. If Sally slipped and fell while on bank property, the bank's liability insurance would be activated. Since she was performing a work-related duty, her worker's compensation coverage also comes into play followed by her employee benefits and finally her coverage through her husband's benefits.
Sally returns to work Everything returns to the order as in Sally's initial arrival at work.
Sally leaves in her car for lunch Everything returns to the same order as Sally's drive to work. Lunch is not a work-related activity, so an accident here would not involve her worker's compensation coverage.
Sally returns to work Everything returns to the order as in Sally's initial arrival at work.
Sally drives home Everything returns to the same order as Sally's drive to work.
Sally arrives home Everything returns to the order in place when Sally woke to get ready for work.

Obviously there are many other possible scenarios. Sally could be older, divorced or still working part-time while drawing Medicare benefits. General illness, an accident at home, an accident at a local business or an automobile accident would all create different lineups of which coverage is first, second, third, etc., in terms of billing order.

Another basic rule is that most policies can be classified as traumatic or nontraumatic. Traumatic policies are typically automobile, workers' compensation or liability. Nontraumatic policies are typically employee benefit, Medicare, Medicaid, supplemental and others. The differentiation between traumatic and nontraumatic is not only important in establishing the batting order, but also in diagnostic coding. Traumatic situations require 800-level codes. Nontraumatic situations typically require 300- or 700-level codes. Filing a traumatic diagnostic code with a nontraumatic policy, or vice-versa, will generate questions of primary and secondary coverage in most cases. There are exceptions to this rule, but they are just that - exceptions.

The first number in the diagnostic code provides a great deal of information about a claim. This number describes the mode of onset (traumatic vs. nontraumatic), the possibility of pre-existing conditions, primary and secondary possibilities, and the practice personnel's coding abilities.

With an understanding of the batting order, the question becomes, "What are the questions the patient must answer in order to get started on the right foot?" The specific questions come primarily from the history of the present illness/injury (HPI) that is a part of every case history. The content of the HPI includes the onset of the illness/injury. In some cases, simply asking about the onset of the illness/injury may be enough. The case may be straightforward. In most cases, however, the questioner has to dig for information. Patients often tell you what they want you to know, not what you actually need to know.

This brings up another important factor in starting well. Patients think the billing order is their decision. Not surprisingly, their order is usually based on the best financial scenario for them. For example, a patient may have a $500 deductible through his employee benefits. He is also covered through his wife's benefits with $10 co-pay. He will obviously want to use his wife's employment insurance as primary. Who wouldn't? However as stated previously, insurance rules and policies, established by state agencies, dictate which coverage is primary. The patient's employee benefits are always primary and the spouse's benefits are always secondary.

While the questions necessary to start on the right foot are typically asked by the doctor during the HPI, many can be asked by staff members during their initial contact with the patient. This can occur by phone or in person. The staff should be intimately involved in establishing the batting order, as they will be filing the claims.

The two most basic questions are: "When did your pain/dysfunction begin?" and "How did your pain/dysfunction begin?" The patient may answer the questions specifically ("Last Tuesday in a car wreck") or vaguely ("Over the past few weeks. I'm not sure"). Obviously, a specific response is desired. The vague response requires further questioning. Questions include:

  • Did your pain/dysfunction begin suddenly or gradually?
  • Have you experienced the same/similar symptoms in the past?
  • Have you been treated for same/similar symptoms in the past?
  • Have you been treated for this episode? By whom? When?

If the answer to questions about onset include statements such as, "I've had this off and on for 20 years," additional questions will be necessary. Considering the typical patient's memory and knowledge of health care issues, and the probable lack of previous records/information, it is impossible to tell if the current episode is anything but similar.

Just because the symptoms are in the same region as previous episodes does not mean the cause of the symptoms is the same. Listing the onset as "20 years ago" will raise questions of pre-existing conditions and carrier responsibility. Questions such as the following [first four bulleted points below] will help narrow the onset date to a more specific date. If the patient is vague about the cause of illness/injury, ask additional questions [last four bulleted points] in order to get the patient to provide more detailed information:

  • Have you reported your current trouble to anyone? Who? When?
  • Have you consulted or been treated for your current condition?
  • When did your current condition become severe enough to try home care (e.g., a heating pad or over-the-counter medication)?
  • When did your current condition become severe enough to consult a health care provider?
  • What were you doing during the
  • 48-72 hours prior to the onset of your condition?
  • Where were you when your symptoms began?
  • Did all of your symptoms begin at the same time? (If the answer to this question is no, ask in what order the symptoms manifested.)

While conditions of unsure timing and origin are more problematic, a few additional questions may also be necessary for conditions with more specific timing and origin. "Where were you when your illness/injury began?" and "What were you doing when your illness/injury began?" are helpful.

While all of the questions I recommend asking may seem intense, they are very important at the initiation of every case. When taken in consideration with the patient's available coverage, these questions will help establish the batting order of the carriers involved and increase your odds of starting and finishing well.

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