February 2007

IME guidelines published

Document explores appropriate review procedures

Any chiropractor who has been in practice for any period of time has no doubt been the subject of a so called "Independent Medical Exam." Until now chiropractors have had no authoritative guidelines to turn to in order to determine whether or not the process followed was appropriate.

With the publication of "The Independent Evaluation of Chiropractic Care: Guidelines for Peer Review," this is no longer the case. The Guidelines were written and edited by. Matthew McCoy, DC, and include contributions from several well known and respected chiropractors including:

***  Veronica Gutierrez, DC, Member, White House Commission on Complementary and Alternative Medicine; Private Practitioner

***  Christopher Kent, DC, JD, President, Council on Chiropractic Practice (CCP)

***  Harold McCoy, DC, Diplomate, Applied Chiropractic Sciences; Private Practitioner

***  Stephen Renner, DC, Diplomate, Applied Chiropractic Sciences; Member American Board of Forensic Examiners; Private Practitioner.

***  Terry A. Rondberg, DC, Treasurer, Council on Chiropractic Practice; President, World Chiropractic Alliance

Dr. McCoy is the Vice President of the CCP and oversaw the most recent revision and update of its practice guideline document: "Vertebral Subluxation in Chiropractic Practice." McCoy is active in chiropractic research and has extensive experience as an expert witness in insurance matters, malpractice and regulatory actions.

Over the past several years the issue of standards of care for health professionals has been of serious concern among doctors, insurance companies, government agencies, HMOs, patients, allied health workers and a host of other players. While the health care community, including chiropractic, should be commended for its attention and progress in this area, much work remains to be done.

One area that warrants particular attention is the subject of these guidelines. Independent evaluation is the active solicitation by the payer of health care dollars of another party in order to evaluate the care being rendered.

While guidelines might exist to evaluate the care being given, no formal guidelines existed to evaluate the practices of so called "independent evaluations."

This is a serious concern, since decisions made during these evaluations have an immediate and direct effect on public health and safety.

If an evaluator determines that some or all aspects of a certain care regime are unnecessary, inappropriate or unreasonable, what safeguards are in place to ensure the patient's best interest is the primary determinant of need?

This is especially disconcerting when the party performing or requesting the evaluation has a direct financial incentive to deny the care in question. Guidelines must be placed on these practices and this document is an initial attempt to outline reasonable guidelines which seek to ensure the welfare, health and safety of the public.

"Insurance companies, attorneys, and regulatory agencies make decisions about patient care based on these exams. Until now there have been no standards that chiropractors and their patients could turn to when they feel they have been treated unfairly by an examiner, IME broker or an insurance company" stated McCoy.

Many patients and doctors have questioned the relationship between doctors who provide insurance exams and the companies they provide them for. A great deal of money is paid by insurance companies to doctors in exchange for their opinions about the necessity and reasonableness of care provided to patients. Amazingly, this practice goes wholly unregulated and has resulted in case after case where patients don't get needed care and doctors are denied appropriate reimbursement.

According to McCoy, "When chiropractors get a report or letter saying that certain care was unreasonable and/or unnecessary, t is important for them to understand that they are, in effect, being accused of malpractice and insurance fraud. In other words the report is stating that the doctor provided care that was not needed and then billed for that service."

McCoy emphasized the importance of responding to these damaging reports and not allowing them to go unanswered. By not answering these accusations, the doctor is implicating admitting to the insurance company, the patient, and everyone else, that the accusations are true.

The peer review guidelines cover the following topics:

Introduction ‑‑ An introduction to the independent evaluation process, its inherent problems and possible solutions.

Ethical Issues ‑‑ Discussion and recommendations regarding acceptable ethical standards by all parties involved in the independent evaluation process.

Patient Safety ‑‑ An examination of the issues of public welfare and patient safety in the context of independent evaluations.

Record Keeping ‑‑ Exploring minimal acceptable standards for record keeping in the context of independent evaluations.

Clinical Impression ‑‑ Review of acceptable examination procedures and outcome assessments utilized in the practice of chiropractic. Recommendations are made regarding appropriate evaluation and reporting by the independent evaluator regarding the clinical impression and need for care.

Reassessment ‑‑ Discussion of the role of reassessment in the practice of chiropractic.

Definitions ‑‑ Terminology commonly encountered in the practice of chiropractic which is related to the practice of independent evaluations.

Each chapter begins with a discussion of the topic followed by distinct recommendations that should be followed when peer review is performed.

The doctor or patient who becomes the subject of an IME, board action, insurance denial or other peer review action can then use the guidelines to determine whether or not the appropriate procedures were followed.

Although most DCs think IMEs are only associated with insurance claims, they can actually be used in malpractice cases, board actions, and managed care processes. In all these cases, it is important for chiropractors to know what is and is not appropriate when their lives and the lives of their patients are being affected by IMEs.

The Guidelines are available on line online at www.jvsr.com. Questions or comments regarding the Guidelines can be directed to Dr. Matthew McCoy at editor@jvsr.com.