Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 26
"Lawsuits, Fear and Peace" READ THIS...Every word and follow the instructions
Yesterday, I was retained by an attorney to represent a doctor who was being sued by an insurance company for fraud, over utilization and Federal RICO. This is the third time this issue has come up over a very short period of time. The story is the same for all 3 doctors I have worked with. I also just finished a conversation with a doctor who has ties to the insurance industry, who confirmed that this is a ploy by the insurance companies to make a quick $1-2 million from individual doctors. The sad part is, the insurance company has grounds to prevail in the lawsuits; not always, but most of time, because the doctor got lazy and didn’t play the game and practice under the strictest protocols. Since I have not yet seen the paperwork for the current case, I will tell you what I look for in performing a “chart review” to see if the doctor has any jeopardy.
It starts with the initial evaluation. Were all elements considered and a complete evaluation performed? What were the recommendations (treatment plan)? Most doctors recommend a course of care, take x-rays, and begin to treat. Herein lies the problem. Were x-rays recommended in the treatment plan or just taken? Was a recommendation made for a re-evaluation and was it performed?
Doctors are being accused and found guilty of over-utilization for performing services that were not recommended. It doesn't count if there is a really, really, really good reason to do a test or treatment. It’s not what is done…it’s what is written on paper. Most doctors are very lax in both ordering re-evaluations and performing them in a timely fashion. Federal Medicare standards state the patient “SHALL” be evaluated every 30 days. In audits that I have been involved with, Medicare, PI and managed care alike, the standard is simple; if you satisfy the Federal Standards, then every carrier in every state will be satisfied with your standard of care. If you are treating your patients for 60-90-120 days with no re-evaluations, you are exposed to serious repercussions if audited by a carrier or a governmental agency, and you will have little or no defense.
The next item to look for on a chart review is the diagnosis. Are all diagnoses the same for every patient through the entire course of care? Does the IDC and CPT cross link? The most common finding is the diagnosis of a cervical condition and a lumbar x-ray. In addition, the doctor bills for a 3 region adjustment and only diagnoses 2 regions. These are all considered billing FRAUD. Sound like “splitting hairs?” It is…and it isn’t. It is always about the money, and an insurer is in business to keep their money and/or get as much back from you as they can. Do not give them a reason.
- Initial evaluation, including recommendations for all x-rays and referral considerations
- Re-Evaluations every 30-45 days and follow your treatment plan
- Change the diagnosis as care progresses, based upon clinical findings
- Diagnose every area that you are adjusting
- Diagnose every area the you x-ray
These are hard rules that can NEVER be altered. The best way to practice is from strength and never fear; document-document-document…and keep your money and sanity.