Are Your Patients Being Harmed by Chiropractic Managed Care Networks?

The American Chiropractic Association (ACA), as part of its ongoing aggressive campaign to correct the wrongful practices of certain chiropractic managed care networks, is asking doctors of chiropractic nationwide to provide additional information that will assist in putting an end to these practices. Among the wrongful practices that the ACA is gathering information about are the following:

• Automatic downcoding or limiting physician discretion in the planning of care: The doctor submits the network's forms after examining the patient and is advised of the frequency, duration and type of care that will be covered. Requested treatment is often reduced or denied. Claims are downcoded without the doctor of chiropractic being provided the opportunity to provide any documentation supporting the claim as submitted.
• Bundling: The submitted CPT code is incorporated into another submitted CPT code.
• Improper utilization review, including refusal to recognize coding modifiers: Managed care organizations sometimes refuse to recognize "modifiers" that chiropractors append to CPT codes to report a service or procedure that has been performed and which has been altered by some specific circumstance.
• Performance management issues: Managed care networks often disregard the doctor's discretion to diagnose and treat, and limit the number of visits, X-rays and modalities. Doctors say they are reprimanded and threatened with the loss of their contract when the care they prescribe is outside the managed care organization's set standards.

Over the past three years, hundreds of doctors of chiropractic have contacted ACA and completed "managed care data collection" forms, detailing their troubling experiences with chiropractic networks; the names of several specific organizations have emerged. According to the data collected by ACA, doctors of chiropractic are most troubled by the actions of American Chiropractic Network (ACN), American Specialty Health Plans (ASHP) and Landmark Healthcare. These carriers routinely deny requested treatment and improperly reduce and deny reimbursement, putting patients and quality of care at risk, according to doctors who contacted ACA. The following eight-point summary regarding ACN/United Health Care is not a final document or a legal analysis, but it does provide an excellent overview of some of the information that has been obtained to date.

1. Illusory Benefit: A benefit is advertised to the employer and employee/patient that is not available for use because ACN reviewers routinely will deny requested care based on "medical necessity." Thus, the patient may have paid for a 20-visit benefit, but can not use it as they or the doctor feel is needed.

2. Evidence-Based Guidelines: ACN attempts to keep chiropractic care within restrictive boundaries supposedly justified by evidence-based guidelines. The information they reference consists of articles and studies that show how chiropractic was not effective for the type and duration of certain treatments. This literature is available upon request or can be found on the ACN Web site: www.acnprovider.com. ACN states that United Health Care does not provide coverage for rehabilitative care; they will only provide for symptom (pain) relief.

3. Coding Issues: Doctors complain about denials of adjustments and therapies being done together. ACN routinely denies more than one therapy being done during a visit. Evidence received indicates codes that are billed are changed to different codes and paid at a lower rate. Changing the code changes the medical record of treatment provided and is very serious.

4. Treatment Decision-Making: ACN does not regard the provider's medical judgment and requires that their own forms be completed so that ACN staff (who have never examined the patient) can determine the appropriate plan of care. These forms are a cursory description of the patient's problem and are not a sound basis on which to judge medical necessity. The CPT definition for the exam encompasses taking the history, performing the exam, and medical decision-making. The doctor does not have an effective manner through which to elaborate the complexity of the patient's history, and patients must describe their symptoms by bubbling in preset responses on the Neck or Back Index. If more than one answer is appropriate, the patient may only select one. Data must fit into ACN's format so that physician performance can be monitored. ACN's operations manual states that notes should be submitted when CMT codes above 98940 are used and when X-rays are needed, but they are never requested, and when submitted, are never read. When doctors are placed on the Performance Improvement Program because of "overtreatment," they are threatened with loss of in-network status based upon the treatment that ACN has authorized.

In some states, ACN clinical consultants (doctors) are not licensed in the state they are working in, and an argument has been made in one state that these doctors are practicing medicine without a license.

Patients whose condition necessitates a higher frequency or duration of treatment are often not allowed the care they need. The end result is a poor outcome that leaves the patient dissatisfied with chiropractic treatment in general and may mean that they will not seek it again.

5. Peer Comparison: In addition to questionable literature and research, ACN determines medical necessity based on statistical data of care delivery on similar patients by one's peers. When the care delivery of a DC does not fit into ACN's statistical benchmarks, they determine that the care was not necessary. The statistical flaw is that the doctors they consider to be comparable peers are also being threatened with loss of revenue, patients, network status, etc., and to stay in the network are either undertreating, or providing treatment that they do not bill for.

ACN is now beginning to review out-of-network "peers" as well, but the problem is that now they too are having their performance measured and can be threatened with loss of the right to treat UHC patients. As a result, ACN does not have a valid statistical control group (either in or out of their network) to compare to.

6. Punitive Treatment: ACN appears to be attempting to reduce benefits for chiropractic to cover only minimal problems that can be treated with a few visits. Other than cost control, there is no justification for telling doctors, "You have too many 98941s, too many X-rays, and too high E/M codes." This punitive treatment is in direct conflict with the AMA's standards for Pay-for-Performance Programs (www.ama-assn.org/go/pfp), which state that such programs should do the following (my emphasis added in italics):

• "Ensure quality of care. This must be the program's most important mission. To ensure that is the case, evidence-based quality-of-care measures, created by physicians across appropriate specialties, must be used. Variations in patient care must be allowed based on the treating physician's judgment and should not affect program rewards."
• "Foster the patient-physician relationship. Programs must not pose obstacles to treating patients based on their health conditions, ethnicity, economic circumstances, demographics or treatment compliance."
• "Offer voluntary physician participation. Doctors must not be forced to take part, and the programs must not undermine the economic viability of practices that do not join. The initiatives must support participation by physicians in all practice settings by minimizing potential financial and technological barriers."
• "Use accurate and fair reporting. Accurate data and scientifically valid analytical methods must be used. Physicians must be allowed to review, comment on and appeal the results before their use."
• "Provide fair and equitable incentives. Programs must rely on new funds. They should reward physicians, rather than punish them. Incentives should be provided for implementation of information technology. Programs should reward all participating physicians who meet the goals."

7. Discrimination: States should identify whether they have equality laws that would provide for the same payment for CPT codes regardless of the treating provider. For example, if a physical therapist is paid to perform an ultrasound treatment, is the same rate paid to a doctor of chiropractic providing the same treatment?

8. Summary: To provide appropriate care that is consistent with their scope of licensure and practice, a doctor of chiropractic must put himself/herself at risk of loss of revenue, loss of patients, and possibly loss of their contract with ACN. For some doctors, ACN patients represent as much as 60 percent of their practice and loss of in-network status can be devastating. In addition, doctors have been barred from signing on as providers in other networks because of having been terminated from ACN.

The guiding priority of doctors of chiropractic must be to improve the well-being of the patient, not the bottom line of managed care networks. Rest assured that the ACA has heard your complaints ... is carefully analyzing the data ... and will take all regulatory and legal steps necessary to help ensure that chiropractic patients receive quality care.

James Edwards, DC
Austin, Texas
jamesedwards@jamesedwards.com