Academy of Chiropractic’s Doctors PI Program
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
“Active vs. Passive Care & Prognosis”
Documentation & Colossus
When documenting your cases, you must realize that there is what you hold to be true, what is generally accepted as true and then what the carriers consider in their algorithm (computer program) for valuing the case. In the past, I have struggled with the ethics of documenting according to the carrier’s algorithm and as a result, sought legal guidance to ensure not only the ethics but the legality of my words and actions.
The legal opinions were consistent and came back that if what we are writing is true and accurate there are neither ethical nor legal boundaries that we have crossed. We as licensed doctors get to decide how we articulate the truth of the case. When determining active versus passive care, the carriers have a specific assignment of what that means as this is one of their “value drivers” in their Colossus paradigm.
Treatment according to the carriers can either be passive or active. Active treatment is that which is done by the patient independent of the Doctor. Passive treatment is what is performed on the patient by someone else. Therefore, it is important to document both types of care clearly.
According to insurance industry experts, unless the injured is involved in their own rehabilitation and recovery it can negatively impact the value of the case. Please understand that Im not concerned about the value of the case only the treatment of the patient, however you must understand the full ramifications of your treatment orders. The reason treatment orders come into play in this scenario is that active care is a direct sequela of ordering a home exercise program.
Many patients independently perform active care, which ranges from walking to getting massages to taking naps during the afternoon to allow their body to rest. These are all valid forms of active care; however, none gets documented and the provider does not have any feedback on helping to guide your patients through the rehabilitation process and concurrently the carrier has no evidence of your patients participation in the recovery because it didn’t get documented.
NOTE: this is another area that I strongly agree with the Colossus algorithms. Patients must be involved in their own recovery on an ongoing basis (usually a lifetime) as couch potatoes rarely do well in the long term.
In addition, this lends itself to rendering an ongoing prognosis, which accurately reflects when a patient is within their care. The following is a list of prognoses that Colossus assigns, and I agree because they work.
A – Undetermined
B - No complaints/No treatment recommended
C - Complaints/No treatment recommended
D - Complaints/Treatment recommended
E – Guarded
Prognoses must be included in every reevaluation and must be updated according to the condition of the patient.
When considering ascribing a prognosis to your patient, treatment is a strong consideration and most chiropractors often have a demented perspective on treatment. We typically consider the patient being treated only when they are being adjusted or putting modalities on the patient. That is a misconception and a mistake. An evaluation is treatment, taking an x-ray is treatment, helping a patient with exercise is treatment, rendering a home exercise program is treatment you recommend. Therefore, too many doctors would choose when rendering a home exercise program in the absence of passive care in your office as category C, which would be incorrect. Should you be recommending a home exercise program in the patient still have ongoing complaints, Category D would be accurate and should be considered.
It should also be noted that many carriers algorithms will not consider impairment ratings without a Category D assignment of prognosis. In addition, without impairment rating neither duties under duress or loss of enjoyment of life will be considered. There is a bias built in with some carriers who will only accept an A-B-C category prognosis from a chiropractor leaving the D prognosis for medical doctors although I have seen evidence to the contrary. Therefore, medical co-management from a Colossus algorithmic perspective can be beneficial.
This brings up the next significant issue and that is one of clinical necessity: is medical co-management clinically indicated? Too many doctors “as a matter of business” refer to medical doctors regardless of the clinical necessity and that can be both an ethical and concurrent licensure violation. In addition, it can be considered fraud and other charges that are valid because a referral must be solely based on clinical necessity. With that being said, I often refer out to my medical counterparts to get a second opinion to confirm my diagnosis and ensure I missed no underlying pathology. However, my clinical rationale for the referral will have been clearly documented.
Regardless of who the Colossus algorithms accepts a prognosis from, I would still use the rules above as they reflect a clinically accurate scenario and many carriers to accept the chiropractor’s opinion on this issue. However, I still have medical doctors that I work with for second opinions and when clinically indicated I seek their counsel and share with them these parameters should they feel its appropriate to include in their documentation.
I do want to conclude by saying that the chiropractors opinion is often the sole source of documentation and we are seeing settlement values rise as a result with the understanding that the carriers are continually updating their algorithms. I am also certain that any current and future updates will be to further limit payments to doctors for treatment, lawyers for Settlements in patients for ongoing necessary support as the carriers have always held profits first.