For you doctors who have never performed a claim review, try this exercise. Obtain from a colleague (whose office procedure and record keeping you are not familiar with) a case involving relatively long-term care and a high number of visits, with multiple therapies and repeat examination procedures. Take the insurance claim forms, copies of the SOAP notes, and examination forms (which you probably will be unable to understand) and try to justify the diagnosis in relation to the examination findings. Then see if you can objectively justify the treatment rendered to the diagnosis presented. Believe me, it takes a great deal of benefit of doubt. Forwarding copies of x-rays is of little benefit because, as stated earlier, you cannot decipher 90 percent of the x-ray markings and examination forms, and daily SOAP notes are illegible.
Granted, most insurance companies employ reviewers who cut the most from claims the greatest percentage of time, just as you buy office supplies from the company that has the highest quality products for the best price. However, I believe that most reviewers are doctors in private practice who do these reviews as a form of service to the profession. Personally, the income from reviews and ICEs do not equal even one percent of my income from private practice, and the time required to review the claim and dictate the report is worth much more than the modest fee paid by the carrier.
Full-time claims reviewers may be a horse of a different color. I have seen some that bordered on the ridiculous and were extremely degrading. But think about this: which person would you rather have to review your claims -- a claims adjuster with a high school education or GED, a department supervisor with an anti-chiropractic attitude, an RN, or a fellow chiropractic physician? I think that you would choose the latter.
For any claims reviewers that read this article, think about this: Some services and/or procedures may not be performed in the vast majority of chiropractic offices, e.g., thermograms, nerve conduction studies, and computerized muscle testing; but these procedures make good documentation of necessity and efficacy of treatment. Remember there are many procedures that only a couple of years ago were disallowed as being not usual and customary, but are now common practice. I can remember when an additional charge for physiotherapy, comparative x-rays, or examination after the first two to four weeks was disallowed by insurance carriers and reviewers on a regular basis.
Here are a few suggestions that will greatly reduce or even eliminate utilization reviews. Remember some reviews are based on total charges, but most are based on the number and frequency of treatments, length of time, and auxiliary services such as physiotherapies and examination/diagnostic procedures. First of all, when an insurance carrier calls or writes requesting additional information, do not become belligerent, thinking that this is just chiropractic harassment or that you have been singled out for the "screw Dr. X" week. Be polite, congenial, specific and prompt in your responses. If copies of case records are requested, make certain that the records are legible; if not, transcribe the records in typewritten form and attach it to a copy of the original record. A brief case summary report, which is a necessity for workers' compensation and personal injury, should be sent immediately following the initial examination. A case summary report is not necessary and is not recommended for group insurance type claims; however, in the event of a request for additional information or in the event of a utilization review, a case summary would be of enormous value.
For those who are unfamiliar with a case summary, it is a very brief outline form of report containing only pertinent findings. Below is a simple outline and, as the name implies, it is only a summary, not a wordy narrative report filled with mostly negative findings.
Case Summary
Date _ _
Patient's Name _ _
SS# or Case # _ _
Chief Symptoms:
1.
2.
3.
4.
History:
Brief statement of what and how symptoms came about with pertinent contributory history.
Pertinent Examination Findings:
ROMs in degrees; positive or significant physical, orthopedic, neurological, and chiropractic findings.
X-Ray Findings:
Brief summary of pathologies, degenerative changes, structural aberrations, etc.
Diagnosis:
1.
2.
3.
4.
(ICDA code numbers with a brief word diagnosis.)
Treatment Plan:
Approximate number and frequency of treatments, and the length of time in weeks or months.
Expected Response:
This is a prognosis. It also enables the claim reviewer to see a starting and approximate ending date.
Perhaps this will be of some assistance in minimizing your insurance claim difficulties. I know that if I should be called upon to review one of your cases, a case summary along with updated summaries as the patient progressed would be of tremendous benefit, plus reduce the likelihood of having benefits reduced.
Donald L. Bryant, D.C.
Amite, Louisiana