Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 54
"Managed Care Agreements"
First, I must apologize, as this consult has nothing to do with a personal injury practice. However, there is a growing concern that you need to be aware of to protect your practice. Yesterday, I received a call from a doctor in Connecticut that is not part of the Lawyers PI Program, as he was referred to me by a colleague of his. This doctor has a modest family practice and hasn't changed his documenting methods in years, as he is “focused on healing," as that is his purpose. Aetna performed a retrospective review that went back to 1992 and their special investigative unit (SIU) wrote a demand letter for $48,000 based upon his utilization of interferential stimulation and the use of 98942.
He is no longer focused on healing; he is now focused on saving his money. It never ceases to amaze me how principled healers always lose their principles when their money is at stake! Why can't everyone be principled and pay careful attention to the details? Then you get to be a healer and hold onto your money.
I explained to this doctor that it is not personal, it’s business. Aetna wants to make more money and he was their “cash cow,” as most chiropractors have become easy targets because very few pay attention to documenting correctly. It’s very simple; it’s easier to get money back from doctors because insurance utilization reviews show that chiropractors are not focused on documenting care accurately. We have been our own worst enemy!
My experience in working in medicine and chiropractic reveals that medical doctors document much better. It’s part of their culture because as a profession, the medical world went through retrospective reviews long ago and this wave is first hitting chiropractic now “en masse.”
Regarding Aetna and interferential stimulation (e-stim), the reason this doctor will have to write a large check is the managed care agreement. The agreement that the doctor signed, but never read, clearly states:
- Aetna considers interferential stimulation (e.g., RS-4i Sequential Stimulator) experimental and investigational for the reduction of pain and edema and all other indications because its effectiveness for these indications has not been established.
You don't have to agree or like with this statement; it is a non-arguable issue, as you have already signed the contract/ agreement with the company when you signed up with them. Therefore, the doctor who performed these services in a very small practice, over time, now has to refund a significant amount of money for these services.
The question asked is, “Why did Aetna pay in the first place?” The answer is they cover TENS for the first month of care and the codes are the same. In addition, a review of the 98942 supporting documentation did not support that code. I have not reviewed this doctor’s documentation, as that will happen in a few weeks when I work to get his reimbursable amount lowered through a forensic audit.
Here is the complete link to Aetna’s Policy:
On a procedural note, take all of your managed care policies, put each in its own 3-ring binder and read them, focusing on practice guidelines of services that you render, along with their timely submission policies.