Is the treatment medically necessary?
Document to show need
By Skip Freedman, MD

Case managers, utilization managers, and nurses for health insurers sometimes have the unenviable job of rejecting healthcare claims.

It’s their job to evaluate procedures, including chiropractic techniques, based upon medical necessity. However, it’s difficult for them, as medical generalists, to have a complete understanding of the chiropractic specialty.

This means that it’s up to chiropractors to understand what case reviewers are looking for — and to provide it or not be reimbursed. It’s also important to understand that questionable cases are often passed on to a third-party, or independent review organization (IRO) for a decision. The IRO sends the claim to be scrutinized by a chiropractic physician, who evaluates it strictly on medical necessity, established facts regarding medical necessity, and proven medical care guidelines.

WHAT IS MEDICAL NECESSITY?

Medical necessity is usually defined very broadly by health insurers. It requires that chiropractors or any other physician provide “prudent clinical judgment” when diagnosing, evaluating, or treating a patient’s illness, injury, disease, or symptoms. To meet the requirement for “prudent clinical judgment” a treatment must meet the following criteria:

• The treatment is not for the convenience of either patient or physician;

• The procedure follows generally accepted standards of medical practice, based on credible scientific evidence published in peer-reviewed, medical literature, and is generally accepted by the relevant medical community;

• Proscribed treatments are clinically appropriate in terms of type, frequency, extent, body location, and duration, and considered effective for the patient’s illness, injury, or disease; and

• The treatment costs no more than an alternate service or sequence of services and is just as likely to produce similar therapeutic or diagnostic results for the patient’s illness, injury, or disease.

Unfortunately, this definition isn’t specific. There is no case reviewer checklist to help you. To understand the evaluation process better, let’s look at this subject through the eyes of a case manager.

For the reviewer, burden of proof lies with solid, detailed medical documentation in the patient’s case file.

For example: “Patient’s head tilts 30 degrees to the left” provides the reviewer with more information than “patient’s head lists to left.”

For you to help case managers evaluate the medical necessity of a patient’s procedure means documenting the patient’s case folder thoroughly. Each case hinges on the quality of the information that you provide. It’s the chiropractor’s job to assist case managers by supplying all the medical evidence needed to make a medical necessity decision within the limits of the patient’s healthcare plan.

By providing more detailed clinical information for a medical review, you help the patient and the health insurer and improve the reimbursement outcome. This means that every visit must be well documented and the patient’s status or progress noted.

By providing comprehensive information, you increase the efficiency of anyone reviewing the patient’s case throughout the case review process, because it’s easy to see the patient’s complete condition and make an assessment about whether the plan covers all or a part of the treatment.

If you do not give reviewers all the information required to make a decision based on medical evidence, you leave them two options — either reject the claim, or in rare cases, request more details from you.

But what do you need to provide to a case manager? Here are some examples of documentation that helps reviewers.

• A complete medical history of the patient regarding the condition under review;

• Documentation of any conservative medical practices (if any) already applied to solve the health problem. (In other words, what accepted practices were done and with what results?);

• In cases of trauma, an outline of the extent of the trauma, how it happened, conditions under which it happened, and so on;

• Clear documentation of any tests (i.e., range of motion, reflexes, neurological, or orthopedic) as well as structural problems;

• Descriptions of any changes in the patient’s condition.

In addition, keep in mind that patient notes are more easily interpreted by a reviewer when they quantify the patient’s condition before and during treatment (for example, the range of motion or degree of motion needed to reach pain).

This quantification shows either that the patient continues to improve or that the patient has reached the point of improvement at which care can be discontinued. Further treatments will no longer affect the patient’s condition.

Another factor that reviewers look for is whether a chiropractic case meets or exceeds medical care guidelines, such as those from the American College of Occupational Environmental Medicine, Milliman, or, where accepted, the Chiropractic Quality Assurance and Practice Parameters (commonly called the Mercy Guidelines).

These guidelines provide chiropractors with standard practices accepted by many health insurers. In addition, they provide access to evidence-based knowledge and best practices relevant to their patients in a broad range of care settings and make specific recommendations about the number and duration of manipulations of the neck, spine, and shoulders. (These guidelines tend to disregard other joint manipulations, based on the current peer-reviewed literature.)

Most frequently, their criteria recommends a two- to four-week time frame and between eight and 12 manipulations, about two to three a week. Except in extraordinary cases, independent chiropractic reviewers who examine cases exceeding these guidelines usually approve only the number of treatments the guidelines recommend.

While few medical professionals argue about the value of chiropractic treatments in the first few weeks after a patient’s injury, they all seem to agree that to date, peer-reviewed studies show little evidence of the value of long-term, or maintenance, chiropractic care, and the guidelines tend to see this as going beyond the scope of medical necessity. Therefore, most health insurers are hesitant to pay for such long-term care.

Every reviewer looks at the patient’s file for specific details about the patient’s condition. If it is not there, the case may be rejected outright. Claims evaluation is a volume business and allows little time to go back and request missing information. The well-documented patient file gives a complete picture of what is happening with the patient. It results in a fairer decision about the procedure for both the patient and the health insurer — and it’s based solely upon the medical necessity of the treatment.

Skip Freedman, MD, is the medical director at AllMed Healthcare Management (www.AllMedmd.com), an independent review organization based in Portland, Ore. He is a longtime emergency room physician and practices at several hospitals in the Portland-Vancouver metropolitan area.