November 2003

Office notes: Curse of the umpire

by Dr. Jeffrey Shay

You know the drill. You take care of a patient and submit a bill, but nothing can happen until your office notes are submitted to the carrier. Or, maybe you're a member of a PPO that requires submission of records before giving treatment authorization. Even worse, Medicare or some other carrier is demanding notes in a post‑payment review, in order to decide whether your treatment meets guidelines.

If you're dealing with a personal injury case, you might as well start printing out your records while the patient is still in the treatment room.

Whether we like it or not, the demands for submission of office records now dominate our office work, often taking more time than it did to examine and treat the patient. So what's up with that?

I can remember when I used to treat my patient, type up a HCFA‑1500 and submit it, receiving my check in a fairly short period of time. Please note that those days were not that long ago. I'm not that old. My teeth haven't been loosening. I didn't witness Harvey Lillard's first adjustment. And I didn't see Old Abe leave on the train for Washington. Most of these changes have occurred in the last 10 years.

A lot of things have happened since then.

Health care in America has been going down the drain, with carriers (including government ones) trying to find ways to reduce health care payments. Less delicately phrased, the carriers have created their own reasons for refusing claims. They've even had some help from people in our own profession.

In a nutshell, carriers have decided to require doctors to meet certain record keeping guidelines based on "agreed‑upon" treatment standards. Who agreed on these standards is never explained to us in most cases. Usually, it's some in‑house experts at the insurance company who've been transferred over from pulling the wings off of flies. They make up their own rules as they go along, a little like the White House.

However, there has been some connivance from this profession, mainly in the form of the Mercy Conference. The theory behind Mercy didn't seem so bad. Create a set of rules for chiropractic treatment that would categorize treatment. If the standards were met, then the insurance companies would pay, thus encouraging standardization.

In real life it worked differently.

The standards were written by a small group of people in the Fuhrerbunker, located near ACA headquarters. Other chiropractic groups had no input. Heck, even ACA members didn't have any input. I should know, I was an ACA member at that time, and I was amazed at the way these guidelines were railroaded through. I really was in ACA then, but I don't have any tattoo on my arm to prove it, like their initials or a skull‑and‑crossbones. The Mercy guidelines played a large part in my departure.

If doctors didn't meet Mercy guidelines, they wouldn't be paid. If they did, they still weren't guaranteed a check. Once the genie was out of the bottle, the insurance groups moved in like jackals surrounding a carcass.

Carriers hired "chiropractic consultants" (often a nice term for "hired guns") to review the records. When Johnny Ringo was called out, very few chiropractors could pass muster. Usually, records were refused with generic remarks, and little substance. The results were consistent, in that the insurance company was always a BIG winner.

These consultants appeared on every street corner, and even some state chiropractic groups and one college got involved. In short, the profits created decay. The only losers were the D.C.s who actually treated patients. I should note that the WCA does not condone the activities I have described, and has condemned this kind of review.

It still continues.

I had an attorney recently demand notes on a P.I. case. Being familiar with this dude, I knew he probably hadn't read any of them. As a matter of fact, I went to school with him, and he even moved his lips when reading "Dick and Jane." I submitted more than 40 pages of notes, while adding several pages of notes around page 10 in Latin. He never noticed. He simply stated that his review did not show definitive need for chiropractic treatment (what he always said about my notes, which in this case looked like the third act from "The Exorcist").

Back in high school I had always wondered if there would ever be any use for having to conjugate "amo, amas, amat" in class every day. I probably couldn't have imagined this scenario.

It worked so well, I sent in a page of Latin notes in the middle of a treatment authorization from a PPO, receiving authorization the next day. This confirmed my suspicion that the reviewer had made up his mind before even asking for the records. The other possibility is that my records are being reviewed by a Dominican monk.

There are several answers to this problem.

First, we need new guidelines based on REAL chiropractic standards. In other words, rules based around the reasons for adjusting patients. Most chiropractors would meet these standards easily.

Second, the profession needs to identify the "hired guns," and strip the veneer of respectability from the review business until solid standards exist.

Third, we should create a "batting average" for reviewers. In baseball, hitters are rated by the number of hits they make, divided by the number of plate appearances. Therefore, a batter with three hits in 10 appearances is hitting .333. Using similar standards, a reviewer who hit only .128 would be in hot water.

Fourth, reviewers should not be allowed to throw out entire visits when records are missing a few details. If a doctor consistently forgets to include a pain rating, he or she should not have to forfeit the entire treatment. Penalizing at 10% should get the message across without confiscating the entire visit.

I should note that the ACA did not create this monster, but has served it much in the manner that Igor served Dr. Frankenstein.

Recently I received a records request from my carrier, Noridian. I had to send the notes to justify two visits that were considered excessive (12 chiropractic visits in a year were obviously an abuse). The records were rejected by a reviewer and Medicare got to keep the money.

Let's see, Medicare hires someone to review my records, he rejects them and Medicare gets to keep the money. This is basically the same procedure for appeals used in the former Soviet Union.

When I called Medicare about this travesty, I was told that my records were repetitive and therefore not payable. My records were only for two days, so how repetitive could they be? The records showed treatment for a thoracic injury, with each day showing a different pain rating, a different amount of muscle spasm, and a different range of motion.

Granted, there is some repetition, but when you're treating the same vertebra each day, that's a given. In my mind, they showed improvement. Not mentioning some things twice would be like reviewing the California governor's race without mentioning movie actors.

When I requested to speak with the reviewer, I was told that neither he nor Bin Laden could be located. I would not be allowed a review since the amount in question was under $100.

Recently, Medicare sent out a bulletin on electronic record keeping, warning that systems that were repetitive could result in payment refusals. I called the carrier about this, but they refused to give specifics on software standards. They weren't required to state what was wrong in my records, merely that they did not meet their standards. In essence, the carrier is going to use the same system one Supreme Court justice used in a case some years ago when he said, "I know pornography when I see it."

After some thought, I figured out the problem. I should have submitted the notes in Latin.

(Dr. Jeffrey Shay, a graduate of Palmer College of Chiropractic and the WCA's 1996 "Chiropractor of the Year," is the World Chiropractic Alliance Director of Insurance Relations. He welcomes comments or questions regarding any insurance‑related subject appearing in this column. Dr. Shay is available to speak to your state or local organization. Contact him at 1300 Cedar St., Muscatine, IA 52761, or the WCA offices, FAX 480/732‑9313.)