The Advocate Update Report --  February 2003
by Dr. Matthew McCoy, Chair – WCA Chiropractic Advocacy Council

Necessary & Reasonable

Here is a true story. It’s not an isolated story as I see it all the time, but it is one of the scariest I’ve run across on this topic.

A bunch of subluxation-based chiropractors are going about their business taking care of patients. They all have family practices so they see mom, dad, the kids and grandma. Many of these patients all have major medical coverage with a particular insurer. These chiropractors take care of these people, eventually insurance coverage runs out at some point during the year and they are switched to cash. At various points the insurance company sends out EOB’s denying certain services because they say the care is not “necessary” and they reduce reimbursement amounts because fees are not “reasonable.”

The chiropractors keep caring for their patients and the insurance company keeps sending their EOB’s.  A couple or so years go by and the chiropractors get dumped from the insurance company, complaints get filed to the state board and the insurance company asks for all that money back that was paid for additional care they’ve determined to be unnecessary and unreasonable. Time to get lawyered up.

The chiros lost. And just one of the arguments by the insurance company was “we sent you explanations of benefits that said the care was unnecessary and unreasonable and you did not respond to one single allegation.”

Like I said, this happens all the time. You get an EOB like that and you ignore it. Who can bother with the paperwork – they’re not gonna pay anyway – right? You get an IME report from the local brothel and it says your care is not necessary and your charges are unreasonable. Instead of going after the IME chiropractor like a pit bull on crack, you ignore it.

Don’t do it. You need to respond to these people and you need to do it every single time. Every time they send you something that says your care is unnecessary and unreasonable they are accusing you of malpractice and insurance fraud. Develop a reputation as one of the chiros who backs up what they do and knows the literature and they will eventually leave you alone and go after the next guy.  

As always, I look forward to your feedback, comments and suggestions.

Dr. Matthew McCoy advocate@worldchiropracticalliance.com
Chairman – WCA Council on Chiropractic Advocacy

http://www.worldchiropracticalliance.org/councils/advocacy.htm