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The best offense to claims denial
Despite your frustration, solutions are available to you to handle the situation. None guarantee success, but they can increase your chances of winning. One major cause of denials is improper documentation. It has been said that football games may be won with offense, but championships are won with strong defenses. Having internal systems in order will not guarantee your claims will be accepted, but you will be prepared to fight back. Before starting legal offensive maneuvers, have a strong defense to carry you to the championship. One of the first, and most important, defensive moves you can take is proper documentation. (Other defensive moves include coding and procedures, understanding the coverage provided, and understanding the company’s appeal process.) DOCUMENTATION WINS THE GAME You will win or lose based upon your documentation and coding. It is that simple. It is not the quantity of documentation that matters, but the quality of the information. Reams of paper containing worthless information — series of macros automatically generated by software — do no good. You do not have to spend 30 minutes documenting each patient. However, you must include, at a minimum, the following: 1. A full and complete history described by the patient. History-taking continues to be a weak link in many chiropractic offices. Doctors seem to focus on treatment and take little interest in the patient’s history. Comments such as “woke up with neck pain” or “twisted wrong and now has low back pain” does not constitute a history. The history establishes the baseline subjective markers for your case. Your subsequent re-evaluations will be compared to this initial information. If your current history process does not accurately describe the degree or severity of the initial condition, then you provide the insurer an increased opportunity to deny treatment. In addition to your notes, include forms filled out and signed by the patient in the patient’s file. When the patient completes a visual analogue scale (VAS), Oswestry, and other similar forms in addition to your intake forms, you get a better understanding of the initial condition, and the patient’s input provides additional credibility and validity. 2. Findings of the initial examination. While the history process sets subjective markers, the examination process sets markers for the initial objective information. Perform an examination that allows you to fully understand the patient’s condition and create objective markers you can evaluate at the daily treatment level and at the subsequent re-examination. The use of examination equipment also helps in the documentation of the degree or severity of the case. For example: A computerized ROM (range-of-motion) test will provide more credibility than eyeballing the patient’s ROM. A cervical range-of-motion (CROM) tool placed on a patient’s head can also accurately reads the patient’s motion in each direction. Another inexpensive tool is a pressure algometer to document pain level objectively. 3. Treatment plan with set goals and targets to achieve. A treatment plan should include more than a recommended number of visits, such as “three times a week for four weeks.” Include targets or goals you intend to accomplish within a specific timeframe. Do you intend to completely correct the condition in this period of time? What level of correction are you expecting? Set a target for the subsequent re-evaluation and re-examination process to judge if the treatment provided was successful or not. Also, incorporate treatment procedures in this section with the intended results. This section sets the stage for the purpose of the treatment modalities and intended results. 4. Signed informed consent to begin treatment. Please see “Do You Have a Valid Informed Consent?” in Vol. 52, Issue 4 (www.chiroeco.com/consent) to review the details of an informed-consent form. 5. Daily records demonstrating progress. Daily notes can be done with check boxes or narratives; there is no single correct way to document daily notes. What is important is the information you capture. The documentation must accurately reflect the patient’s current condition. If your notes read exactly the same visit after visit, then your credibility is affected. Repeated statements of “neck pain” for subjective and only “subluxation” for objective do not create a strong case for appeal of denial. Documentation that includes the level or degree of the patient’s neck pain and more extensive objective observations will. 6. Re-examinations with analysis by the doctor. The analyses should demonstrate progress or termination of care. If you have determined that re-examinations are not valuable, your chance of success in any appeal process is extremely low. The majority of chiropractic claims successfully denied are due to continued care over an extended period of time with no re-examinations performed. Your strong defense starts by establishing the severity of the condition in the initial examination, providing goals and targets to achieve in the treatment plan, and using daily notes and re-examinations to demonstrate progress or response to treatment toward the intended goals. DISCLAIMER: This column is provided for educational purposes only. The accuracy or timeliness of the information presented is not warranted. The information is not presented as legal advice and no attorney-client relationship is established. |
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Insurance companies are denying my claims. Their denying authorities are unknown chiropractors who give me generalized denials on almost all of my care. I feel as though I am being blacklisted. What do you think I should do — hire an attorney and sue them?
The integration of chiropractic into the insurance world has never been a smooth process. Unfortunately, what you are experiencing is not new. 
Steven Conway, DC, DACBOH, JD, Esq., is a partner in True North Chiropractic Consultants LLC, which provides guidance and ethical solutions to the barriers found in chiropractic practices. He can be contacted through