Academy of Chiropractic’s Lawyers PI Program
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
"Insurance Red Flags"
Over the years, I have been investigated, sued, retrospectively audited and in each instance, I have been exonerated from any wrongdoing. However, along the way I have spent in all, over $1,000,000 in cash (non-recoverable funds defending myself to reach that point) in legal defense and I do not want you to be like me (the world's biggest moron/schmuck with a bulls eye on my forehead).
I have always held and still do that we all are going to get audited, however some of us are going to attract more attention than others. The following have been reported by many who have studied the carriers and by lawyers who have defended many doctors in many states as reasons for being flagged at a higher level. I am not suggesting at any level that you shy away from necessary care as a result, however I am suggesting that you ensure that your documentation protects you in every area, with a focus on the following 12 items. In some instances I will be giving suggestions on how I handled these issues in my practice over the last few decades and you can decide on how you choose to move forward.
1. Any claim that there is a lapse in treatment more than 2 weeks from the date of the accident or between active treatment visits
Comment: This is an easy one as I have covered this in previous consultations. However the 2 week interval is a hard number and your patients need to know in the beginning of care that they must give a reason for any lapse in care beyond 2 weeks as it must be documented. Life happens and as long it is on paper, then you can move on safely.
2. Minimal property damage with frequent medical treatment
Comment: Minimal and no crash injuries are intuitively hard for many to understand and that includes carriers. It is a well documented fact in the scientific literature and included in our educational flier series that more get injured with no damage to the car than total destruction of the vehicle. It is here that your credentials will help "carry the day" with the Accident Reconstruction and Spinal Biomechanical Engineering courses. Those courses give you the background, research and words to explain the relationship between causality and bodily injury so that the issue is taken off the table from the initial examination on. It also helps lawyers understand the injuries of their clients much better and realize that you are a true expert in trauma care.
3. Ill defined, or non-existent treatment plan or lack of goal setting
Comment: Too many of you simply do not have a treatment plan and do not re-evaluate your patients in a timely fashion. Most cases I have defended for licensure issues or fraud issues have lost simply because they did not do a timely re-evaluation, nor document a treatment plan after each. This is as simple as it gets and something we ALL Learned in professional school. Goal setting is another simple process. What are your goals? Increase range of motion, increase function, decrease pain...DUHHHHH!!!!!!
4. Any claim with complaints of symptomatology but no actual diagnosis
Comment: You report mid back pain and have no thoracic diagnosis. You report in your history headaches and no diagnosis with any reference to headaches or concussion related diagnosis. This is simple, for every complaint there needs to be a corresponding diagnosis and with no diagnosis, you are precluded from either treating that related area or referring to a specialist for the non-diagnosed condition. Remember, even a general diagnosis for an area is acceptable until a conclusive one is determined with further testing or consultations.
5. Any treatment with no functional improvement
Comment: If the patient doesn't progress under care, then your care is non-effective and should either stop or refer them to a different provider is clinical signs and symptoms persist.
6. Any claim for TENS unit beyond 60 day rental or purchase of the unit.
Comment: I have no clue about this one other than too many doctors in too many states have inflated the bills of the TENS units and passed those bills to the carriers.
7. Any claims for unusual treatment or new diagnostic techniques such as surface EMG or video fluoroscopy
Comment: I have done surface EMG, Video fluoroscopy, spinal sonograms, trans cutaneous neuro stimulation (TCNS) and so much more. Am I against any of these...no. Particularly surface EMG. That technology is one of the best avenues to document spinal muscle spasticity. I understand dynamic surface EMG and my opinion remains constant. If I practiced today, I would employ surface EMG, however I would not bill for it and use it solely as an educational tool for my patients. Every modality, either treatment or testing should be explained to the carrier in a posture of full disclosure with correct CPT codes while being generous with the "xx999" (unlisted) code if you are not sure. In of itself, the xx999 code will raise a flag, but not as much as the wrong code over time.
8. Any treatment of manipulative therapy beyond 12 weeks
Comment: This is a double edged sword because many patients require more than 12 weeks of care. It is here where your documentation must be expansive showing the progression of your patients care with increasing function. Ranges of motion and muscle testing are 2 prime areas that has been accepted universally as to the progression of care. If your patient doesn't progress, then MMI them.
9. Any manipulative therapy where the frequency doesn't decrease over time.
Comment: This ties into #8. See above.
10. Manipulative therapy on a daily basis beyond 2 weeks
Comment: I have treated 1000's of injured patients and can say that 99% of my patients did not require more than 2 weeks of daily care. IF...my patient required to go beyond that, I would call the carrier and have a conversation with them alerting them to why while writing an expansive note in re-evaluation format as to why.
11. Any claims for passive therapy without evidence of a home exercise or strengthening program after 2 weeks.
Comment: First, every patient should have some type of home care program along with education on how not to exacerbate their condition with recommendations on carrying, lifting, sitting, standing, etc... This should be documented in your evaluations and re-evaluations.
12. Repeat office visits billed at 99214 or 99215
Comment: 99214 and 99215 should be limited to re-evaluations. Each visit should be broken down by specific procedure rendered.