Article in Chiropractic Economics:
An Excerpt from Billing and Procedure Denials: What Every Physician Needs to Know, by Dr. Aaron DeShaw, Esq.
"Have you ever played a game without knowing the rules? It’s difficult to win. Over the last 10 years, chiropractors have been playing a “game” with personal-injury insurers without knowing the rules.
Sometimes they win and get paid for their personal-injury (PI) and healthcare claims; sometimes they lose.
The “rules” of the insurance companies are governed by computer programs developed for insurers to cut the cost of claims. Healthcare and personal injury claims, of course, amount to a tremendous sum, as a 1999 study, “Injuries in Auto Accidents: An Analysis of Auto Insurance Claims,” released by the Insurance Research Council (IRC), indicated.
The study noted that $37.1 billion paid to compensate injuries included these payments:
• $19.9 billion for bodily injury (BI) claims,
• $4.1 billion for UM/UIM (uninsured/underinsured motorist) claims,
• $5.1 billion for personal injury protection (PIP) payments, and
• $2.0 billion for MedPay (medical payment) claims.
Despite the fact that PIP and MedPay were only available in about 15 states, these claims accounted for $7.1 billion out of the $37.1 billion paid. Settlements and verdicts on the bodily injury and UM/UIM claims from the entire 50 states accounted for the remaining $30 billion.
The same IRC report revealed that admissions to hospital emergency room departments were down, as well as the incidence of what the insurance industry viewed as “serious” injuries. By contrast, the incidence of sprain and strain injuries rose to account for 85 percent of claims payments.
The providers for most of these types of injuries are chiropractors and physical therapists (PTs), both of whom specialize in the treatment of musculoskeletal injuries.
It is not surprising, then, that the IRC found the highest average payment for treatment of musculoskeletal claims to be to doctors of chiropractic.
As a result of this IRC study and another that preceded it, some insurers took measures to cut claims costs both in terms of PIP/MedPay, as well as in bodily injury claim payments, particularly those involving soft tissue injuries.
Those changes created new “rules” of the payment game you need to know. Here are three.
In the mid 1990s Allstate implemented a claims-processing system called CCPR that segmented claims into different divisions that depend on the facts of the case.
One of the most controversial aspects of CCPR is the Minor Impact Soft Tissue (MIST) claims segmentation. MIST was so successful in terms of claims savings that other insurers adopted it.
MIST operates in this manner: When vehicle damage falls below $1,000, claims are routed to the MIST division of the company and are handled by adjustors who have a limit on the claim payment, often not exceeding $3,000.
If the attorney representing the injured party refuses to accept such an offer, the company is willing to spend many times the amount of a reasonable settlement to defend the case to trial.
The intended result is to make these cases economically infeasible for lawyers to accept, therefore leading to increasingly lower settlement offers. The reduced settlement results in lowering reimbursements for chiropractors who provide care.
Of course there is no scientifically substantiated minimum threshold of injury based upon the forces imparted to the vehicle. But these cases often become clouded by “junk science” from defense biomechanists and engineers.
How do you deal with MIST? Many of the junk science studies have been refuted by Michael Freeman, DC, and Arthur Croft, DC. Review articles these doctors have written and attend continuing education to prepare yourself for trial testimony if you expect full reimbursement on a MIST case.
If possible, work to get these claimed bumped out of the MIST unit.
Many insurers use medical bill review software that considers all healthcare provider billings. The software determines the appropriateness of PIP/MedPay billings and/or ascertains if billings are “reasonable and necessary” for a bodily injury claim.
These programs are set up to reject:
• CPT codes that do not correlate with ICD codes,
• CPT codes that exceed a maximum cap per day,
• Treatment that exceeds a preset duration or frequency, and
• Procedure billings that exceed the 90th percentile of charges in a geographical region.
How to deal with bill review software? Improve your diagnostic coding to reflect the patient’s actual injuries; provide care at a reasonable charge; and make high quality chart notes to support your clinical treatment schedule and referrals.
Approximately 70 percent of the auto insurance industry has implemented claims assessment software — Colossus, Claims Outcome Advisor, or InjuryIQ — to evaluate bodily injury claims.
Based upon the entry of injury diagnoses, these programs trigger screens of questions about a claimant’s case for insurance adjustors.
Colossus and the other programs directly affect the values of bodily injury claims. Yet few lawyers know how to format their demand letters for the Colossus program to obtain full value for the patient’s claim.
The insurance industry planned for this effect. In the 1990s many insurers implemented a “zero sum game” management strategy, in which insurers would increase profits to the extent that they could deprive doctors and injured people from obtaining a full settlement.
How to deal with Colossus? The first critical step is to enter all conditions of the patient as diagnoses in your SOAP notes. Then consider the factors that Colossus values during the course of a patient’s care. Note accurately and objectively whether these factors are, or are not, present.
Finally, write detailed chart notes. Since the Colossus evaluation is almost entirely dependent on the information in your charts, failure to provide detailed notes will decrease the likelihood of reaching an adequate settlement.
Beyond the injuries themselves, here are a few of the more important factors that Colossus uses in its evaluation:
• Complaints. Colossus divides injury cases into two categories: demonstrable and non-demonstrable/soft-tissue.
The non-demonstrable cases are dealt with in a subsection of the Colossus program referred to as the whiplash system, and the value of factors noted in such a case are calculated in a different manner than the factors in a demonstrable injury case.
In addition to the injuries deemed “non-demonstrable,” a number of symptoms add value to the claim. In Colossus, these symptoms are called complaints — headaches, muscle spasms, restriction of movement, radiating pain, depression, and others.
What should you do? Track these complaints for the duration of treatment in your SOAP notes.
• Prognosis. Prognosis is a large value-driver in Colossus. The program does not use the typical medical prognoses, but instead has its own categories, requiring the adjustor to re-characterize the physician’s prognoses. The Colossus categories focus on whether complaints remain and whether treatment is required.
What should you do? Give a prognosis for each area injured.
• Disability. Colossus considers disability in terms and methods different from those used by physicians.
Physicians consider the client’s job description, physical capacity testing, and results from clinical assessment tools such as the Roland Morris, Oswestry, or Neck Disability Indices, to determine disability.
Colossus uses a completely different system called “Duties Under Duress” (one of its top five most valuable factors). To obtain any value for the disability, the injured party’s attorney must specifically address duties in the demand letter. If the attorney fails to do this, the patient will be unable to obtain a maximum settlement offer, and you will face reimbursement reductions.
What should you do? Research and understand what Colossus considers the Duties Under Duress factors and chart problems accordingly.
• Permanent impairment. Permanent impairment is the second most valuable factor in a Colossus claim, preceded only by the injuries incurred.
Colossus is presently set up to calculate values based upon the findings of a “Whole Person Permanent Impairment” under the AMA Guides to the Evaluation of Permanent Impairment 5th Edition.
Claims that do not have an AMA impairment rating fail to obtain the highest potential value in a case evaluated by Colossus.
What should you do? Ensure that AMA impairment ratings with notation of pages and tables in the guides is provided on only those patients with viable permanent impairment ratings, in order to give the insurer the opportunity to evaluate your patient’s claims appropriately.
Aaron DeShaw, DC, JD, is a Portland, Ore., chiropractor, attorney, consultant, and nationally known speaker, who specializes in legal cases surrounding the use of Colossus. He is the author of Colossus: What Every Physician Needs To Know and Billing & Procedure Denials: What Every Physician Needs To Know"