Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 703
Office Systems & Get Paid #56 OS
From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: many of these issues are small, yet each issue is just that… an issue. If you take care of the small issues, then the larger issues often take care of themselves and you can focus on the larger issues… a larger, more profitable practice and more family time.
“Overturn Carrier FRAUD and GET PAID”
I have been sharing with you that the carriers are perpetrating fraud and committing felonies (yes, the “F” word) on a daily basis in order to NOT pay you. They are denying payments based upon the claim adjustors simply being directed to deny your claims in absence of any licensed provider making a medical decision. Meaning, they are denying it because they want to. It no longer matters if this a low speed accident, an ongoing case or just 10 visits with no therapies; they are simply denying it stating the care is medically unnecessary. For a period of time, the carriers took this posture and got away with it, then people like me fought back and challenged them and the profession got paid more fairly. As a result, the carriers instituted a more robust peer review system and upped their game with IME’s and the system turned upside down again with improper IME's and "canned denials," but from credentialed providers.
You get the picture, it is a "cat and mouse" game and the pendulum will keep swaying back and forth. Today, luckily we have each other to figure out how to use the laws in your state to ensure you get paid. In this circumstance, we use "practicing medicine and/or chiropractic without a license and that is the "law du jour" the carriers and their minions; the claim adjustors are breaking and need to be challenged on. In most cases, once threatened with a felony, that carriers jail time for clearly breaking the law the claims adjustors, as a rule overturn their denial and pay the claim. They know they are wrong and do not want to go to jail over this issue.
The only issue with this strategy is that you have to be willing to stand up to a bully and fight. In the end, you will win this battle more than lose and the reason the carriers are doing this, is because too many are afraid to fight for what is right, that goes beyond simply getting paid.
Congratulations Dr. Chester for fighting for your Constitutional right of due process and outlining the actions you will take if not paid. The right has been afforded to you by both the Constitution of the United States (as described in the 5th and 14th amendments to the Constitution) and the laws of the state of Tennessee. Each of us have the same rights in all 50 states and every territory of the United States and this is in part, is what makes our country great!!!!
Dr. Chester wrote:
You may use this letter as you see fit:
I had a patient whose auto insurance carrier refused to pay on the grounds of lack of medical necessity due to gap between MVA and chiropractic treatment (after they initially stated they would cover the cost of my care). The adjuster let us know that, "after independent review," $0 was authorized as medically necessary, and that I needed to call to try to negotiate the bill. He wanted me to negotiate my bill up from ZERO! Anyway, I called Dr. Studin. He had me craft a strongly worded letter challenging the carrier to produce the credentials of the independent reviewer who denied the claim as medically unnecessary. I did, and sent it to him to review. He told me it sucked; par for the course. Then he helped me rewrite it until it was ready to be submitted to the slime ball adjuster. My office manager faxed it that night. Here's the fun part: I got a call first thing the very next morning saying "This is Slimeball Smith, the adjuster handling the case for Mrs...., I received your letter, and after going over the case with my supervisor, we're just going to go ahead and pay the full $4,000." Checkmate, Slime ball!
Thanks, Dr. Mark!
Stephen Chester, DC
There is one reason why our doctors make more money and it is all based upon you knowing the laws, how to position them and using what you now understand, the power of credentials, or the lack thereof to get paid. Otherwise, you will be like most everyone else in the profession, begging and pleading and barely earning a living!
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Adjunct Assistant Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences
Academy of Chiropractic
US Chiropractic Directory
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