September 2008

Embracing the neurologic component of subluxation

by Dr. John Davila

Recently, I had the opportunity to opine on my future goal of redefining medical necessity and embracing the neurological component of the subluxation. The purpose of the article was to facilitate a discussion on the topic of why this is so important. Why is it so important to embrace the subluxation and ALL of its components? And, even if we did, who would care? Why go the extra mile and upset the apple cart as it exists today?

So, why go the extra mile now? I'm sure some of you are saying, "Who cares, I get paid!" That is true, you all get paid now. But, with the rash of audits that have recently hit the health professions (and the audit rate shows no signs of slowing), it really isn't how much you collect, but how much you keep as compared to borrow from the insurance company before they ask for it back. The best part is, I'm so glad I don't feel like Chicken Little telling lies about the end of the world as we know it because of all the articles in every chiropractic trade journal.

Then, as if on cue, Dr. Charles Herring, FCER President, sent an open letter to the profession about proposed legislation in Louisiana. The letter stated: "During the recent Louisiana legislative session it was learned that the National Insurance Commissioners Association has written a model piece of legislation… A major part of this legislation addresses the issue of denying care based on evidence or the lack of evidence. They are attempting to change the rules of the game and will now deny claims because there is no evidence to support the effectiveness of a particular treatment."

This has to be the last wake up call!

Later in his letter, Dr. Herring talks about how research is imperative and required to stop the madness and that we have no one else who is going to work to protect us. The best part is that he is correct on all points. No other group is going to protect the chiropractic interest in any way shape or form. But, I think we need to look at the possibility of research helping practicing doctors in a timely manner.

Over the years, I have had the opportunity to work in and around major medical insurance companies as a consultant. As a very involved Carrier Advisory Committee Member for Palmetto GBA, I was given the task of re-writing the chiropractic LMRP. In addition, I had the opportunity to train nurses and talk coverage policy with executives well above the din created by the uninformed chatter on chiropractic from the medical director.

The problem is the executives who make the final decisions don't care about our research. Unfortunately, it's the truth and the truth hurts. In fact, a few years ago I was asked to create a pilot chiropractic program within a large work comp insurer to compare chiropractic to PT in low back pain cases. Our first case was an emergency cervical case thrown in because the patient didn't want the surgery he was scheduled for after six months and $40,000 of PT, meds, office visits, injections and diagnostics.

In less than three weeks of chiropractic care, the patient was 100% and back to work for under $800. Immediately following the patient's release from care, the project was cancelled! You could imagine my surprise as I was given the news. Here was the hard proof the carrier had been asking us for and then beat us down in spite of it! The nurses respected the work we did but the executives didn't care. They didn't want the new information. They wanted the information they already had regarding their policy decisions to be the same information we would use to prove our point.

If we take this experience and extrapolate it out, we will find there are a few reasons why research is not the answer. First, legislation like the type mentioned earlier can be brought in over the course of weeks or months as compared to the time it takes to produce research. Research can take years to complete, take more time for it to be published and then be adopted by those outside the profession. In other words, we are out of time!

We do not have the luxury of having years to create a research project, compile data, publish it and have the carriers accept it. Let's be honest, new research is not going to be a quick fix -- any more than starting the process of drilling for oil when gas is four dollars a gallon. By the time drilling is started and produces any useful amounts of oil, it'll be three-to-four years down the road. Meanwhile, we'll be paying up to five or six dollars a gallon for gas.

There are two simple solutions to the dilemma we face that can be taken on today. The first is to provide a level of defense your practice needs to survive in today's environment. That first step is called an internal audit. The internal audit is performed so that you always know what your practice profile looks like before the carriers do. Why is this important? Because if you know where your mistakes are, you can change them before the carrier catches on.

Remember, every insurance carrier (not just Medicare) profiles every practice based on the claims submitted. The process of performing your own internal audit can virtually eliminate the chances of a post-payment audit ever being conducted on your practice. Because of this, it is imperative to make your practice look as solid and bulletproof as possible in the eyes of the carrier so that they latch onto another target.

The second part of the solution starts where an old saying meets chiropractic's major problem. Southerners often confess that no matter how many ribbons you put on a pig, it's still a pig. The same is true about our practice and its profile. If we only change the way we bill, eventually an audit will happen (just from blind luck) and the carrier will see the parts of the practice no one ever sees. And we all know that part is the way we apply the carrier's definition of medical necessity to our patients' conditions.

If we take the lessons learned from past dealings with the carriers, we can learn that all they want to do is rely on the old reliable data they have used for years. All we have to do is take that information and fill in the spaces to allow the chiropractic "square peg" to fit in to the medical model's "round hole." We do this by taking research that the carriers rely upon and finding a common connection back to the subluxation and the chiropractic adjustment. Sounds tough, but it's not.

Recently, I had the opportunity to spend time with Dr. Richard Barwell and have his instrument, the NeuroInfiniti measure my body's reaction to stress and what I found was amazing. His instrument was able to pick up stress-related problems and give them a quantifiable measurement before an adjustment was given. After an adjustment was given, I was re-analyzed and the NeuroInfiniti has shown that my reaction to stress had reduced. The best part is that this was all based in common medical research and technology that has been applied to chiropractic and our most beloved part of the subluxation, the neurological component. Think about all the times we have stated from our heart that there is a neurological component to what we do but in order to claim our piece of the medical pie we have talked for years about low back pain.

This type of exam can unite our profession and change how we practice forever. For subluxation-based chiropractors, it could show the relationship to stress and the subluxation. For others who believe rehabilitation to be a major part of what we do, it can help show neurological proof of re-innervation of a muscle from a combined treatment plan of chiropractic adjustments and therapies. Best of all, it takes the patient's current neurological condition and measures the improvement after the adjustment and that is the part that will change how we practice forever. We owe it to ourselves to look at the possibilities that the NeuroInfiniti could create for all of us.

What a happy day it would be to use existing and accepted medical research to show proof of the neurological component of the subluxation without waiting another second. By continually performing internal audits and using the technology contained in the NeuroInfiniti, we can change how the insurance companies view our practices and define medical necessity today.

(Dr. John Davila is vice president of Compliant Services & Solutions, Inc. He is a compliance expert who helps chiropractors defend themselves from audits and creates customized compliance programs. Dr. Davila can be reached at team@compliantusa.com or by calling 877-322-6203. CSSi can be found online at www.compliantusa.com).