Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 1176
Office Systems 104 OS

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

"Overturning an Improper IME"

 

Dr Studin: So the purpose of this conversation is to look at a pure review from a chiropractor from which insurance company?

Guest Dr: USAA.

Dr Studin: USAA right now is the biggest perpetrator of inappropriate denials, but I'm looking at the actual pure review here, and so what he says is upon review of the submitted documentation for the patient, the opinions expressed in this report or hearing are based in part on my training skill, experience and associated peer literature based upon the records submitted for review was my recommendations of the services delivered on 6/18 through 6/26/2019 are not medically necessary. My decision is based upon the following. So he went on in the state that he saw you with complaints of neck and back pain. You'll examine the patient noting the subjective complaints and recorded the objective findings. You've got initiated treatment but you say here, although your exam did elicit several positive findings, a cause or relationship between the condition of the motor vehicle collision and motor vehicle accident was not established. Now, there was no indication of any complicating factors that would delay cover your or required prolonged treatment beyond the natural history of recovery. Now number one, did you causally relate the accident to the symptoms?

Guest Dr: I did.

Dr Studin: so he perjured himself. He's saying it was not a sufficiently established, you have the records in front of you?

Guest Dr: I do.

Dr Studin :And how did you establish that? can you read that to me please?

Guest Dr: I could. The Injuries sustained by the patient are consistent with the nature of the trauma on and then the date that the trauma happened.

Dr Studin: so he's saying because the relationship was not sufficiently established so therefore he lied. That's number one. Number two, no indication of any complicating factors that would delay recovery or prolonged treatment beyond the natural history of recovery. There is no there literature showing that spine problems don't naturally recover. So there's literature showing it's wrong. You're familiar with that literature?

Guest Dr: No.

Dr Studin: There's literature that says that that's wrong. The natural history of covered is the anticipator covery either with conservative treatment or without conservative treatment. So that's a lie. It's just the literature is just beyond that. The initiation of treatment over 18 weeks post loss is not appropriate. So the doctor used crystal ball stuff and again, this is why you evaluate the patients. It's not about two weeks, five weeks, eight weeks, 10 weeks. And it's not about natural recovery it's about the last evaluation that was done within a 30 day bite. so according to numerous studies, research and guidelines, treatment is justified only during the acute and subacute healing phases between eight to 10 weeks. And then this recommendation is supported. So therefore he supports it by the MD guys see valuation of disease And injury causation. Second edition, I happen to have that the practitioner's manual Liebenthal rehabilitation, the spine, clinical application of outcome assessments. This is just absurd. So he lists these clinical application of outcome assessments and this is auto injury solutions. This is their pre templated report. Now, and since you have a additional documentation referring physician records become available, please submit for reconsideration. So then he apparently had your records.

Guest Dr: Yes, we send our records with it.

Dr Studin: Treatment guidelines us with the initial constituent post loss. So therefore the answer is, 72100 x-ray, I don't know what that code is for CPT.

Guest Dr: That is x-ray of the lumbar spine.

Dr Studin: He doesn't recommend treatment for the 99204, which is the initial evaluation.

Guest Dr: Correct.

Dr Studin: And x-rays because it's more than 18 weeks post loss. Correct?

Guest Dr: Correct.

Dr Studin: Even if the patient has ongoing continuing problems.

Guest Dr: And she had been doing treatment from her medical doctor.

Dr Studin: Injury recovery solutions is wonderful. So here's what I do when an IME rebuttal. They should go to dr Benoni, He's the guy who we work with who I saw IME rebuttals, and you can't go after for licensure issues, because even though he lied a little bit, he's quoting guidelines versus your evaluation, he didn't write this report, Auto injury solutions wrote this and he signed his name to it, you need to get dr Benoni to write a rebuttal for you. I think he gets like $150. He works for himself, but he's doing this for almost 40 years and he's really good at. You cannot let them have the last word on this because this will, this will set your reputation.

Guest Dr: Yes, I agree. what they denied is nonsensical, basically, it's not for one and then approved for, Oh, that they changed on their own.

Dr Studin: So it's not, it's not nonsensical. It's business. It's good business on their part and they're not used to people fighting back. Too many people don't do it and get screwed, but you're should understand something, you're a second generation chiropractor and you're coming up the ranks. The issue is that your reputation matters a lot. And this is all public record. So your reputation matters. And you have to be careful. Cause if they push you around now, it never stops.

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