Editor's Note: This article completes the sample appeal outline Dr. Farabaugh introduced last article (September). Part 1 of the sample outline showed how to present case facts.
Part II: Response to Negative IME / File Reviewer Comments
Please consider the following issues related to this appeal.
Issue #1: ODG. "Dr. XYZ stated the following: [list the exact language he used, taking it directly from his/her report]"
Response: Identify where the IME deviated from ODG language or state law. [Ex.: Ohio law does not require ongoing improvement and allows for supportive care when necessary. "I challenge the review to produce the page, paragraph or sentence from ODG proving that I deviated from ODG guidelines. If he/she cannot produce the exact reference, we can only assume he/she literally fabricated this issue, which resulted in this patient being denied their rightful benefits in the workers' compensation system in Ohio."]
Other issues:
- Using ODG like a cookbook
- ODG is not a cap in care or an artificial guideline
- Appendix D: Exceptions to guidelines
- Copyright page: requires IME consider the uniqueness of each patient, etc.
- There is no such thing as "chiropractic care." Chiropractic is a professional licensure, not a treatment.
Issue #2: Complicating factors. "Dr. XYZ stated the following: [list the exact language he used, taking it directly from his/her report]"
Response: "There were numerous complicating factors / prognostic factors and co-morbidities including [list them here]. Note that the IME did not consider virtually any of the complicating factors identified in this case. It is inappropriate for an IME/file reviewer to simply ignore all important medical facts to support his/her predictable denial. Since this reviewer essentially ignored all important facts in this area, his/her report is not persuasive and has no credibility. His/her denial is fatally flawed and biased against the injured worker."
Issue #3: [Keep listing all errors in the IME report and provide rational, non-emotional responses to each item.]
Summary: "In summary, the medical facts of this case are clear. The errors, miss-statements, omissions of fact, misquote of ODG, and biases are equally as clear. Therefore, I respectfully request that the care requested initially be allowed so this patient can continue to receive the medically necessary care that has been proven to be of benefit, and is afforded to this patient under the rules and regulation of work comp in [your state here]."
The Power of Guidelines
There are a great many applications of CCGPP/Clinical Compass guidelines regarding your practice. The ultimate goal is to not only provide better care to our patients, but also to educate non-chiropractic physicians as to the science and benefits of chiropractic-driven health care. We need your help to spread the word.
Dr. Ronald J. Farabaugh, past chairman of the CCGPP, been in practice since 1982, and has published on chiropractic guidelines and case management. Recently, he was elected to the Council on Chiropractic Education (CCE) as a Councilor-Category 2, representing clinicians. In 2015, he was positioned as the National Physical Medicine Director for Advanced Medical Integration Group, LP. He is also the founder/owner of www.chiroltd.com, an evidence-based, patient-centered, practice-management company dedicated to assisting DCs establish a more evidence-based office and referral mindset.