You Can’t Always Get What You Want

“I just don’t understand this insurance company. They always reject my claims, calling them maintenance care. Why won’t they pay?” the doctor lamented. “I even called them, but it didn’t help. I think they pick on chiropractors. Sometimes I think they don’t like us.”

Does this sound familiar? Consultants and software developers hear a lot of complaints from chiropractors about how uncooperative, discriminatory and annoying insurance companies can be when they reject perfectly legitimate claims. It’s easy to become frustrated when you are forced to justify every treatment, to communicate every move made on a patient’s behalf.

The complaints about insurance carriers permeate the healthcare profession. Every doctor, regardless of specialty, fumes over the amount of paperwork required. Chiropractors are not alone in the insurance paper chase.

Pinpointing the Problem
If you receive an initial rejection from an insurance company, you can use this list of six questions to help you re-evaluate the claim and pinpoint the reason for the rejection:

1. How long has the patient been under chiropractic care?
2. What was the initial diagnosis?
3. What changes have occurred in the patient’s symptoms since the initiation of care?
4. What changes have occurred in objective findings?
5. Have the changes in status/progress been reported to the insurance company on a periodic basis?
6. Has the patient experienced a new injury or a re-injury, an exacerbation of his or her symptoms or a different condition or symptoms during the course of care?

The results of these questions can sometimes be astonishing. The questions should be viewed as a way to evaluate your effectiveness at communicating the critical details of a patient’s care. Let’s review them in-depth.

1. Length of Care: “If it looks like a duck, walks like a duck and quacks like a duck, it must be a duck.” In the insurance processing game, if your claims for a particular patient look like maintenance care, they must be maintenance care, especially when that viewpoint gives the company an excuse for rejecting the claim. If the course of treatment exceeds three months and visits decrease in frequency to one or two per month, it does look like maintenance care.

The insurance carrier is responsible for reimbursing services until the patient reaches the maximal level of improvement. Once the maximum correction has been achieved, the patient is technically receiving “maintenance care,” or care that maintains the current level of functionality. Unless you can prove otherwise through your documentation, you are fighting a losing battle.

2. Initial Diagnosis: The initial diagnosis will be based on a combination of subjective (patient complaint) and objective (examination and X-ray) findings. Subjective findings might include pain or changes in sensation, such as hyperesthesia or hypoesthesia. Objective findings are used to formulate and substantiate the patient’s diagnosis; they might indicate fixation or rotation of certain vertebrae. They might also involve muscles, ligaments and tendons that move in conjunction with the spinal column. Objective findings may include indications of pathology or biomechanical dysfunction. They pinpoint the various areas of involvement and the severity of the condition.

The initial diagnosis sets the stage for determining the length of the treatment plan necessary to correct the condition. A diagnosis of pain or subluxation is most likely viewed as less severe than a sprain/strain or a degenerative condition. The level of complexity of the patient’s condition, as reflected in the diagnosis, determines the framework for subsequent treatment.

3. Changes in Symptoms: As the patient undergoes treatment, he or she will report changes in symptomatology. On an initial interview, a particular patient may complain of severe low back pain radiating into the right leg and buttocks. Also, she may experience a secondary complaint of periodic headaches. As her course of treatment progresses, she may report that the pain in her low back has decreased and that the burning sensation in her leg is almost gone. Her headaches, however, have remained the same. All this information is classified as subjective findings: the patient’s report of his or her condition.

Subjective findings are important because they constitute the patient’s reason for seeking treatment. While subjective findings justify the need for initial treatment, symptomatic changes justify the need for ongoing care. On a status report, you might indicate “patient reports that low back pain has lessened in intensity, resulting in a decreased burning sensation in the right leg.” Keeping the insurance company apprised of the patient’s progress lowers the risk that the insurance company may choose to stop reimbursement prematurely.

If you want to quantify changes in symptomatology, you can use a pain scale or improvement scale. Both of these devices yield a measurement that can be used as a yardstick for progress. Suppose that the patient initially reported a 9 on the pain scale for low back; after two months, the patient reports a 5 or 6 at each visit. This change indicates that improvement is being made, but there is still room for progress to achieve a lifestyle that is as pain-free as possible. The various scales provide an attempt to quantify something that is inherently subjective. As the patient reports the scores, though, the progress can be measured.

4. Changes in Objective Findings: This question assumes the patient has been evaluated prior to each adjustment (range of motion, spasm, fixation, pain, leg check etc.), as well as undergone a thorough re-examination after a certain period of time (usually two to three months). When performing a re-examination, every positive finding on the initial exam should be retested to determine any change. The results of the re-exam should be correlated with the patient’s report of changes. It is important to evaluate progress on a periodic basis.

5. Status or Progress Reports: In the movie “Field of Dreams,” the farmer, played by Kevin Costner, was told, “If you build it, they will come.” That’s exactly what happened. The farmer built a baseball diamond and players magically appeared out of the cornfield, followed by droves of spectators. In comparison, let’s look at the insurance game: “If you bill it, they will pay?” In your dreams! There is a clause in many insurance contracts – medical necessity – that is used to disqualify any procedure used as preventive care, such as well baby check-ups or annual physicals. The care provided must be medically necessary to treat a current condition, not to prevent a future problem. Even if you use the correct CPT and ICD codes for every billing, there is no guarantee of payment.

Most chiropractors realize the key to getting insurance reimbursements is documentation. To get paid, your claims must meet the litmus test for medical necessity. Assuming you have followed the previous steps perfectly, you must communicate the results to the insurance carrier. The insurance company does not know that the patient is responding well to care unless you report the changes in the subjective and objective findings that you have meticulously recorded. Your in-house documentation must be translated into a report that the insurance clerk will read and understand.

6. Condition Changes: There are countless situations that can cause a condition change. Here are a few familiar scenarios:

• A patient who is undergoing treatment for low back pain suddenly wakes up with severe torticollis. Sometimes the patient knows what precipitated the condition, and sometimes the problem just happens.
• Sports injuries are as much of a part of summer as mosquitoes and picnics. A “desk jockey” becomes a softball jock, sliding into home during a softball game and hurting his neck by slamming into the catcher’s leg. Prior to the softball heroics, his headaches had virtually disappeared. The softball injury exacerbates his original cervical problem.
• Lifting a heavy basket of wet clothes, a young mother strains her low back. Of course, she still has to care for (and lift) her 9-month-old baby.
• A patient hurt his low back at work. Before he is released from care for the Workers’ Compensation claim, his car gets rear-ended while he is stopped at an intersection, and he sustains a whiplash injury.

Documenting changes in a patient’s condition is extremely important. No longer are you treating the original problem; now there is a new condition, and maybe a new diagnosis. In essence, this change resets the clock, initiating care for a whole new problem and a new series of treatments.

Documentation Guidelines

It is much easier to prevent a rejection than to fight one that has already occurred. The key to proactive insurance reporting involves timely and succinct update reports. The following list describes the types of reports that should accompany your claims.

• Periodic status reports showing changes and improvements. These reports should include an updated diagnosis as the patient’s condition warrants. When it comes to SOAP notes, quantity is never a substitute for quality. A concise but accurate report accomplishes the main objective, which is justifying medical necessity. These status reports should be sent every month or two if the patient continues treatment for an extended period of time.
• Immediate documentation of a new injury to a different area of the spine or re-injury to the same area of the spine. This type of situation often occurs during the course of care. Let’s take a typical example. The patient has been under your care for cervical problems. While shopping one day, she slips and falls in a local grocery store. In an attempt to avoid the fall, she grabs a counter and wrenches her low back. This new injury begins a new cycle of care, and a new insurance carrier will probably be involved because of the personal injury. Obviously, it would be important to report the details of the injury as well as the new symptoms and exam results.

With a Workers’ Compensation injury, it is not uncommon for the problem area to be re-injured, especially if the patient or the employer ignores restrictions meant to protect the patient. A common example is the patient who lifts too much or lifts improperly, re-injuring the low back. If this occurs, it is important to re-examine the patient, establishing the groundwork for continued care. Pay particular attention to the patient’s report of increased pain and any exam results that substantiate the change. If you begin treatment for a different injury, this change necessitates an updated report with details of the injury, new diagnosis and a new treatment plan.

• If the patient displays a different condition or symptoms, notify the insurance company through a report. Suppose the original problem was neck pain and headaches. After a few months of good results responding to care, the patient comes into the office with excruciating thoracic pain that makes breathing difficult. This situation will require additional visits that would not have been necessary otherwise. Unless you specifically tell the insurance company, the carrier may terminate reimbursement prematurely or not understand the need for an increased frequency of visits.
• Exacerbation of symptoms. Sometimes in the process of chiropractic care, the patient will experience a partial reversal of the progress that had been made. At that time, the doctor may choose to perform additional diagnostic tests, send the patient for a consultation, and revise the diagnosis and treatment plan. An exacerbation, with or without a precipitating cause, should trigger an update report.

When you fail to provide reasons for insurance companies to continue paying for your care by documenting medical necessity, you are setting the stage for rejections. Once you receive a formal denial, it is much more difficult to get it reversed. Once a claim is denied initially, you have to request reconsideration of the claim and wait for the review process. The review process can take two to four months, depending on the company. During that time, the insurance company is holding your money.

Reaping the Rewards

By learning to give insurance companies what they need to justify necessity, you reap the rewards. The result will be stacks of insurance checks rather than stacks of rejection letters. The bottom line is that documentation works. Of course, providing periodic status reports is a time-consuming process unless you have some tools to help you. That’s where SOAP notes software comes in.

Finding the Perfect Match

Once you have decided to invest in SOAP notes software, the search begins. You will find many different packages are available, each with its own strengths and weaknesses. How do you narrow down the search?

• Determine who will be doing the data input. This consideration is probably the most critical issue. Some doctors love computers, others hate them. If you will be inputting the data, you should consider a pen-based, touch-screen or bar-code program, because they are easier to manipulate.
• If your staff will be inputting the data, the method of entry is not as important as the ease and speed, and the interface between the doctor’s notes and the data input. Some systems include sample exam forms and fee slips that the doctor can check off. A checklist type of fee slip makes it easy for the doctor to record findings and equally easy for the staff to input the data.
• Look at sample output. In my experience, many insurance processors want simple, concise summaries. Attorneys and Workers’ Compensation companies tend to request more lengthy, detailed reports. Since the desired output varies by recipient, the program you choose must be flexible in the reports produced. If you have a question about the type of report certain insurance carriers, attorneys or government agencies prefer, contact them ahead of time.
• Find out the hardware requirements. A pen-based computer will likely cost between $2,500 and $4,000 for the hardware alone, especially if you want remote networking. However, since the pen-based computer is portable, you would need only one for each doctor in the clinic. A touch screen costs $700 to $800. To use touch-screen technology effectively, you would need computers with touch screens in every treatment room. The cost for computers with touch screens would be approximately $1,450 per treatment room.

Another feature to consider is voice recognition software. If the SOAP notes software supports it, you can dictate directly into a note, adding details about a recent accident or unusual circumstances. Obviously, if you want to add voice recognition, you would also need good sound cards and voice software (around $250). Each of these potential hardware options must be coordinated with the SOAP notes software.

• Test the SOAP notes software for ease of use. If the SOAP notes program increases rather than decreases the workload, don’t buy it. In addition, if you can’t learn to operate the program within a two- to three-hour timeframe after installation, look elsewhere. Then, once you know how to use the software, try using it during actual appointments. Remember that a SOAP notes program should save time, not waste it.

Playing the Game

You need to follow the insurance companies’ rules to achieve better reimbursement levels. If insurance reimbursement is viewed as a game, documentation moves you a few spaces forward. When you reach the goal, you collect the prize.

Involve your entire staff by discussing documentation at your next staff meeting and work together to find a solution that works best for your office. Improving your documentation is worth the investment of time and energy, and it pays great dividends.