Decisions by claims review personnel in the employ of insurance carriers directly affect the continuation or termination of third-party payment of claims. The emergence of an unregulated class of decision makers, and the imposition of their economic authority between the DC and the patient raises serious questions about quality of care, and presents a potential threat to the professional autonomy and status of the practitioner.
The ICA board hopes to foster an expanded discussion of the issue of insurance consultants, and contribute to the development of practical and effective administrative or legislative solutions through which fair treatment in the insurance process can be secured for patient and chiropractor alike.
In the present health care economy, peer review for appropriateness of care supplied by all classes of providers is a necessary and established fact. Because of the unique and non-duplicative nature of the science, art and philosophy of chiropractic, the decisions of a chiropractor on the care of a particular patient can only be accurately and competently evaluated by another DC actively practicing in the same geographic area.
DCs reviewing case files to determine if care should be continued are obliged to bring the same technical, professional, and ethical considerations to that process as they would apply to a patient in their office. Judgments must also be based on a complete evaluation of all records and files without revealing the identity of the provider.
Independent physical examinations of insurance beneficiaries to determine validity of claims must be performed by practicing DCs. The patient must be given ample advance notice (at least five working days) with the treating doctor and their representative as well as the patient and their witness having the right and opportunity to be present for the entire IME process, and the right to receive a copy of the IME doctor's report in a timely manner.
The payment of DCs for reviewing insurance claims raises serious ethical questions. The ICA acknowledges that there are circumstances under which this is appropriate, but holds that chiropractors who agree to accept a percentage of claims reduced as compensation, or who enter into agreements guaranteeing to reduce reviewed claims by an established percentage, have crossed an ethical boundary and are engaging in unfair and grossly inappropriate behavior.
The licensing and regulatory boards in the various states are the appropriate authorities to regulate the operations of insurance consultants. The ICA will support efforts undertaken by the chiropractic community to legislate state certification of insurance review consultants, including programs of education, and certification via accredited chiropractic colleges.
The ICA seeks to establish, in a cooperative effort with other chiropractic associations, an agreed statement of insurance review principles and methods. Such a statement of practical and ethical guidelines could then be communicated to the insurance industry as the acceptable basis by which claims reviews might be conducted.
Of particular concern is the degree to which insurance companies promote the comprehensive nature of their products in vigorous marketing programs. In operation, however, the plans often then seek to interpose care evaluation criteria based on their own (often economically based) standards. The gap between the provider's judgment and the industry standard is then explained to the beneficiary as inappropriate or unnecessary care. Chiropractic must demand truth in insurance marketing, and accept no standard that does not provide for the optimal care of the patient.
The ICA stands ready to cooperate in a broad-based nationwide campaign on the part of the chiropractic profession to establish insurance review procedures that are ethically sound, economically fair, and which will insure that the insurance industry and the chiropractic profession can collectively meet the legitimate health care needs of the insured patient.
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