May 2006

Documentation: Red herring?

by Dr. Jeffrey Shay

For some years, a number of leaders in the chiropractic profession have been demanding that chiropractors adequately document their patient contacts. The penalties have been a two‑edged sword. Some insurance companies have refused to pay for chiropractic treatments due to "inadequate documentation," while others have demanded refunds for what they perceive as over‑treatment.

The newest battleground is Medicare.

A report issued by the Office of Inspector General (OIG) of the Department of Health and Human Services takes a derogatory view of the way chiropractors document their services, or fail to do so. According to the report, supporting documentation for chiropractic services rarely meets all Medicare Carriers Manual requirements.

The report goes on to complain about several areas of concern, including medical necessity, maintenance services, supporting documentation and possible over‑utilization.

For some reason, Medicare feels medical necessity is connected with the volume of services, and that services rendered over 12 visits per year may be more likely to be unnecessary, with the likelihood of unnecessary treatment to be increasing with every visit. Which all presents the problem of over‑utilization, which, according to the report, exists despite carrier efforts to prevent this and other mortal sins.

All of the above is also contained in an article that appeared in Dynamic Chiropractic (DC). Readers of chiropractic literature may recall that DC has the same relationship to the American Chiropractic Association (ACA) as a mirror has to Snow White, as in "Who's the fairest of them all?" In addition to Medicare's position, DC also gave the ACA's response. The ACA, of course, can seldom be accused of overstating the chiropractic case.

The ACA felt that the findings of the report... "reflect a universal problem in physician documentation and do not represent a concerted effort by doctors of chiropractic to overbill the government." It pointed out that chiropractors are basically failing to document the medically necessary care that they deliver. The ACA then went on to question the validity of using arbitrary limits, as is continually done by most insuring agents.

As usual, the ACA's position only addressed the documentation problem on a superficial level.

First of all, the idea of a concerted effort by chiropractors to over‑bill is ridiculous on its surface. We're not taught to over‑bill in our colleges, nor do approved classes exist showing how to dupe Medicare. A secret group of chiropractors trying to bilk Medicare makes about as much sense as the Mafia planning to knock over the Salvation Army.

Remember that chiropractors seldom work together like other medical professionals, who work in groups in hospitals and clinics. In my experience, we probably consort with each other less than other providers. Also, when was the last time you saw a course titled, "Cancun on 30 Medicare Patients a Day"?

I agree with the ACA's stated position on arbitrary limits, and the right of patients to receive necessary care. No problem there.

There are several problems with Medicare's position that the ACA does not address. One is knowing the qualifications of the people who review the records. How many of these people have any experience with chiropractors? How many are patients? The answer is probably none. Remembering that we are in a minority profession, we have to wonder about the initial bias of the reviewers. To paraphrase Butch Cassidy, "Who are those guys?" Are they nurses, physical therapists, secret agents or Hitler Youth? Who reviews the reviewers?

My experience has been that most Medicare records are reviewed by nurses. It goes without saying that they have no knowledge of our procedures, and from what I've seen, it doesn't seem to bother them a whole lot.

Several years ago, I talked to a Medicare investigator, who, when I asked him to describe an adjustment, made a wrenching motion with his hands. When I told him about other techniques, he looked confused. When I described Logan Basic technique (a technique that spawned one of our largest colleges) I thought he was going to hyperventilate. The fact is that he was investigating a profession he knew nothing about.

The second question should concern the origin of the standards. Where did the idea of 12 adjustments come from, other than one treatment a month? On that basis, shouldn't heart patients be allowed one nitro per month? How about giving stroke patients one therapy treatment a month and then see what kind of progress they make?

The ACA accepted at face value the claim that chiropractic documentation was insufficient. Arguably, sometimes it is. In other cases, the refusal to credit the doctor's records dovetails with Medicare's desire to save money. Medicare should not review records without use of a disinterested outside agency. We also run into this problem with insurance companies regularly. It's like, "Should I pay this chiropractor for adjusting Mr. Smith four times in June, or should I divert the money toward golf club membership for the fascists who pay my salary?"

By the way, an article in Business Week magazine reported that a significant number of heart specialists now believe that most by‑passes and angioplasties are unnecessary and a waste of money and should be curtailed. If you think that Medicare is now going to declare these operations as maintenance treatment (and findings seem to indicate that they are), you probably are also planning a trip to Des Moines to see the Butler Cow. Also note that the Butler Cow is not the only tourist venue in this state. Iowa is rich in history and heritage. There's always the world's largest Cheeto in Algona, or the tractor parade we had here in Muscatine a little over a year ago.

Question 1: What will Medicare do since studies are showing many heart procedures to be a waste of time/money?

A. Immediately stop payment and save the taxpayers millions.

B. Conduct a post‑payment audit and make the surgeons cough up the booty.

C. Audit more chiropractors for seeing patients over twelve times.

D. Recommend patients see chiropractors for treatment that will save lives and money.

Anyone who's taken multiple choice exams knows the old rule: "When in doubt, check C." If you checked D, you're unreality gauge is topping out. Check your arm for needle tracks.

By the way, the same article noted that a high percentage of back surgeries were also not considered necessary by experts, especially fusions. Do you think that Medicare will demand repayment for all the money wasted on back procedures and encourage chiropractic care instead? Not likely. We've seen previous articles about failed back surgeries in professional magazines, but when the dust clears, the surgeons are still riding around in BMWs.

The fact is, while sometimes chiropractors do not document well, there's  no distinct agreement about what should be in those records. Not long ago, Medicare requested my records after I had only seen a new patient two times, and had declared my visits as unnecessary. I sent in my records, which I thought were quite complete. I had SOAP and PART. I had my level of subluxation and plan. The reviewer rejected my records as being incomplete. When I called the carrier, they were unable to tell me what was missing...it just was. They also said my records were repetitive, although the findings had improved on the second visit.

Perhaps the reason the ACA forgot to mention mistakes by reviewers is that some of their members have turned up doing dirty work for insurance companies. Or maybe it just slipped their minds.

(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.)