When the Insurance Company Says ‘No’
What You Can Do To Fight Back
By Marty Kotlar, DC

Many chiropractic offices aren’t exactly sure what to do when they receive that dreaded insurance company explanation of benefits (EOB) that states, “Chiropractic services are denied." Insurance companies have many ways in which they can deny and/or delay payment. Is your office properly trained and instantly prepared to challenge all denials?

How is your office responding to the following insurance company EOB comments/requests:

• Benefits are denied because the patient has reached maximum medical improvement.

• The services rendered were not medically necessary.

• Payment for services were included in the procedure.

• The service is denied because it was incidental to the major service rendered.

• Payment will be considered upon review of the chart notes.

• Claim is denied because the service charges are not usual and customary.

• The service is denied because it is included in the contractual obligation and the patient may not be billed for the service.

• Benefits are denied because the diagnosis is inconsistent with the procedure.

• Charges are denied because the claim is incomplete, and/or invalid information is supplied.

• Benefits are not available because the charge exceeds the reasonable fee for the service.

• Claim is unprocessable and no appeal rights are afforded.

• Claim is denied because the charges exceed the maximum allowable amount.

• Procedure is being denied because it is not typically performed on the same date of service as the other billed procedure.

• The charges were applied to the deductible, and therefore payment cannot be made.

• The charges are denied because they were previously considered.

Your office must have a game plan to immediately handle all of these items. Unfortunately, many insurance staff members are not trained to challenge the insurance company reimbursement delay tactics. Nowadays insurance companies are scrutinizing chiropractic claims at an alarming rate.

You must be ready with the proper ammunition to strategically fight insurance companies. While most insurance companies are using cannons to fight the battle, some chiropractors respond by just throwing stones.

The best way to get ahead in this battle is to “track” the denials. You will notice that certain insurance companies use the same denial codes over and over again. They are basically setting up a “profile” that you can follow. Once you know how to interpret what they want and how to get the procedure paid, you’ll be able to anticipate and instantly be prepared to send them the necessary information. This will dramatically increase your reimbursement chances.

Recently, the most common chiropractic service being denied is manual therapy techniques (CPT code 97140) when performed on the same day as a chiropractic manipulative treatment (CPT code 98940-98943).

The two sample letters that appear here can be used as ammunition to challenge the insurance company denials.
Remember that the squeaky wheel gets the grease. Many chiropractors are not “bothering” the insurance companies enough. Insurance companies know that 75% of the denials that get sent to doctors will not get a response. Acquire the necessary knowledge and become part of the 25% that get paid consistently.
Sample Letter #1
XYZ Insurance Company
Address
City, ST 12345

Re: Mr. Patient
ID#: 000-00-0000

Dear Insurance Company Representative:
We are responding to your explanation of benefits that states that you have denied our procedural service of manual therapy techniques (CPT code 97140) because it was billed on the same day along with chiropractic manipulative treatment (CPT code 98940).

The patient presented to this office on (date of service) complaining of severe neck pain (723.1), moderate to severe muscle spasm (728.85) complicated by cervical segmental dysfunction (739.1), recurrent thoracic spine pain (724.1) with associated chronic cervical osteoarthritis (721.0). The patient history and examination findings reveal the fact that the patient has a condition that will greatly benefit from chiropractic manipulative treatment (CPT code 98940) to the affected regions. The purpose of chiropractic manipulative treatment is to increase joint movement, decrease pain and enhance overall neurophysiological function to the affected areas.

The clinical findings revealed that the patient exhibited restricted cervical range-of-motion, shortened connective tissues in the cervicothoracic region, hypomobile joint motion, thoracic muscle rigidity and soft-tissue swelling. Therefore, manual therapy techniques (e.g. myofascial release, manual traction, soft-tissue mobilization, lymphatic drainage, etc.), CPT code 97140, were applied to the affected areas.

We attached the -59 modifier to CPT code 97140 in order for you to note that this procedure was performed separately and independently from CPT code 98940. Please do not attach CPT code 97140 as a component of CPT code 98940. This violates the Medicare mandate that CPT code 97140 is to be used as a component of the chiropractic manipulative treatment (CPT code 98940-98943) and its associated pre- and post-services. This facility performs CPT code 97140 as a separate, distinct and timed service, and therefore we bill separately for it and are entitled to be paid separately for it.

Please re-evaluate your analysis of this claim and contact me at your earliest convenience.
Sincerely,

Sample Letter #2
XYZ Insurance Company
Address
City, ST 12345

Re: Mr. Patient
ID#: 000-00-0000

Dear Insurance Company Representative:
We have received your letter (copy enclosed) dated __________. Based upon our review, we have decided to appeal your decision.

Mr. Patient presented to my office on (date of service) complaining of neck pain (723.1), muscle spasm (728.85) and thoracic osteoarthritis (721.2). The examination findings revealed that the patient exhibited restricted cervical range-of-motion, shortened connective tissue, hypomobile joint motion, thoracic muscle rigidity and soft-tissue swelling. The manual therapy technique of myofascial release (CPT code 97140) was applied to the affected areas. The clinical findings exhibited the fact that the patient would greatly benefit from chiropractic manipulative therapy (CPT code 98941) for the purpose of influencing joint and neurophysiological function to the affected regions.

We would like to provide you with the American Chiropractic Association’s position on CPT code 97140:

“Manual therapy techniques consist of, but are not limited to, connective tissue massage, joint mobilization and manipulation, manual traction, passive range of motion, soft tissue mobilization and manipulation and therapeutic massage. As the code descriptor states, ‘manual’ providers use their hands to administer these techniques. Therefore, code 97140 describes ‘hands-on’ therapy techniques.

Typically, the goals of manual therapy are to modulate pain, increase joint range-of-motion, and reduce or eliminate soft-tissue swelling, inflammation or restriction. These techniques also induce relaxation and improve contractile and noncontractile tissue extensibility.

Manual therapy techniques may be performed on individuals with symptoms that may include a limited range-of-motion, muscle spasm, pain, scar tissue or contracted tissue and/or soft tissue swelling, inflammation or restriction.

Under certain circumstances, it may be appropriate to additionally report CMT codes in addition to code 97140. For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code 97140 to the neck region and CMT to the lumbar region.

As separate body regions are addressed, it would be appropriate in this instance to report both codes 97140 and 98940. In this example, the modifier -59 should be appended to indicate that a distinct procedural service was provided.”We attached the -59 modifier to CPT code 97140 in order for you to note that this procedure is distinct and independent from CPT code 98941. Therefore, both services should be paid.

Please re-evaluate your decision and contact me at your earliest convenience.
Sincerely,

Dr. Kotlar is a senior consultant at Practice Mechanix, Inc. He is a nationally recognized insurance billing and coding specialist and lectures throughout the country on insurance reimbursement issues affecting chiropractic and multi-discipline offices. He can be reached at 800-257-5021, fax; 954-985-2344; or drkotlar@aol.com.