Academy of Chiropractic’s Lawyers PI Program

Infrastructure 136


From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

"Clinical Necessity and Get Paid-Get Paid -Get Paid"

This is about as simple as it comes. For every test you order you MUST have a clinical rationale about what you are doing and how it is affecting your treatment plan. In most cases you must also have an evidenced based reason behind it. Meaning...does the scientific literature support your plan of action.

Doctors are reporting to me that they are not only being denied the test, but because the test was not ordered correctly and had no evidence behind it, ALL care subsequent to that improperly ordered test is now NON-REIMBURSABLE.

Let me put it another way, you aren't getting paid, nor will you ever get paid because you didn't set up your case properly.

This has now been reported to me in multiple states as the "reason du` jour" for non-payment and is trending in our profression for late 2013!

THE SOLUTIONS:

Part of my job is to finds trends nationally and let you know what the future WILL be in your state over time. Whether it is Allstate, State Farm or Blue Cross Blue Shield an insurer is an insurer and they all share information on how to legally, defensibly NOT PAY YOU. It might not be legal in the end, but in the beginning they have a legal argument that can be tied up in the courts and should they lose 5 years from now, you don't get paid for 5 years and when they do lose unless you are part of a class action suit you probably won't see a penny of it. Either way...You lose.

So...let's set you up to win right now!

I have commented on this before; if you take x-rays there must be a treatment order in your initial examination, or prior to the x-rays being taken along with a clinical rationale of why you took those x-rays along with a citation in the scientific literature supporting your clinical decision. It appears at first "blush" to be too much work in order to get paid, but in reality it isn't.

2 years ago, we introduced you to the EMR Macro program (www.EMRMacros.com) which houses evidenced based macros and language for ordering tests and treatment. It is a very inexpensive tools ($50 per month) and resolves the now oft mandated reasons to get paid. WE knew this trend was coming and worked to create an infrastructure to deliver to you the EVIDENCE!

An example of a macro:

Therapeutic Exercises

Relating to the efficacy of therapeutic exercises and lower back pain, the authors of a 2009 Systemic Review stated “The results of this systematic review suggest that motor control exercise is more effective than minimal intervention and adds benefit to another form of intervention in reducing pain and disability for people with persistent LBP [Low Back Pain]. The optimal implementation of motor control exercise at present is unclear. Future trials evaluating issues such as dosage parameters, feedback approaches, and effects in defined subgroups are a high priority.” (p 23)

Luciana G Macedo, Christopher G Maher, Jane Latimer, James H McAuley. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Physical Therapy,Volume 89 Number 1 p 9 – 23.

This is the level of language required to get paid for both testing and treatment for everything we do in our offices. Offices nationally are reporting that collections have skyrocketed with the utilization of evidence and retrospective audits, EUO's and denials have dropped to unprecedented lows.

All that is left is the clinical examination findings that support your decision to order a test. It could be any positive clinical finding from ranges of motion to weakness or sensory loss and must be documented as such.

Trends tell huge stories and because I deal with doctors in 44 states, I get to see trends on a national level and can usually accurately predict what your future will be on a state-by-state basis. It is my goal for you to collect every penny owed for fair and reasonable services.