This was great! We should do it on a regular basis! said a State Farm claim supervisor after the Colorado Chiropractic Association's recent joint insurance seminar, "Can We Talk?" Her comments were echoed by other chiropractors and insurance professionals. The seminar drew about 150 people, about evenly divided between the two groups. Claims personnel from Colorado, Texas, Missouri, and Rhode Island joined adjusters and claims supervisors from more than 16 PIP insurers in Colorado. The major carriers, State Farm, Allstate, Farmers, USAA, and Safeco were all represented, many sending five or more people.
Following a presentation on the effectiveness of chiropractic in the managed care setting by Kim Peerless, RN, vice president of medical cost containment of Ethix/Sloans Lake (ESL), the conferees began roundtable discussions, each hosted by an insurance representative and a chiropractor. The discussions were frank and open, and generally positive.
Ms. Peerless cited statistics generated by ESL's PIP chiropractic program, which showed chiropractic treatment of auto injury cases was cost effective and efficient. Cases treated by DCs resulted in fewer patients returning to the system (needing additional care to resolve their problems) than cases treated by either MDs or PTs. She spoke of the closed nature of the managed care system, and stated that ESL was not currently adding providers because the current supply of patients didn't justify expanding the panel. She explained that providers were added as needed. She acknowledged that managed care requires sacrifices from providers (additional paperwork, and reduced fees), and emphasized that inclusion in a managed care program like ESL may not be for everyone.
Roundtable discussions covering rehabilitation, cost containment, IMEs, managed care, provider-adjuster communications, documentation and coding, treatment guidelines, and treatment outcomes generated good exchange between the two interest groups. Colorado Commissioner of Insurance Mr. Jack Ehnes stated there are over 1,400 insurance companies licensed in Colorado. "We see our mission as focused on the consumer -- the policyholder," he said. Policyholder complaints are down overall this year, although the division is involved in more investigations. "The issue for the '90s, " he asserted, "is market conduct: examining the practice of insurance companies to be sure claims are processed correctly and underwriting guidelines are followed."
"Can We Talk" was a project of the CCA's Insurance Committee chaired by Dr. Richard Lacey. Chiropractic facilitators were Drs. Chris Bender, John Hanks, John Hyland, Larry Morries, Scott Rosenquist, Barbara Walters, Monty Wilburn, Mark Wolff, Mr. Peter Caplan, and myself.
Discussion Summary
DCs and claims' adjusters made the following recommendations: Remove all animosity and prejudicial attitudes from your communications. For doctors, don't assume the adjuster is your enemy; for claims adjusters, don't assume doctors are unethical.
Understand that the other party is also busy. Doctors: Remember that adjusters are often overworked and have many files to deal with; yours is only one them, and it's probably buried in the pile. Adjusters: Remember that the doctor's purpose is to see patients. Respect the DC's time. Talk to each other. Doctors: Return phone calls to adjusters and give them the information they need; answer your mail. Adjusters: Talk to the doctor, not the staff. It may help to fax your questions to the DC. The doctor can then return the call with the answers in hand.
Documentation is annoying, but critical. Doctors: Provide the information requested, and highlight relevant portions of your notes. If you believe you have already sent a particular piece of information, copy it and highlight the part that answers the adjusters questions. Provide complete treatment plan, and include projected end dates. This will help the adjuster understand you know what you are doing, that you have a goal in mind, and when the case is likely to be completed. Adjusters: Ask only for documentation you will read.
Technology is helpful but can interfere with communication. Doctors: Before you fax something to an insurance company, call and let them know a fax is on the way. One fax machine may serve up to 200 people. Adjusters: Use faxes or voice mail messages to communicate. A specific request is more likely to generate a reply than a vague, "Call Mr. Jones."
There may be more to a case than you know. Understand and work with the other party's need to get additional information. Doctors: An auto case may involve coverage applicability, coordination of benefits, or even fraud. The adjuster's job is to sort through all factors to make sure the claim is settled equitably. Adjusters: Let the doctor know if there are questions about coverage or previous accidents. This will help the DC treat the patient more effectively and get the information you need.
Respect the other party's needs and rights. Follow timetables. Doctors: You must submit bills in 30 days, and your patient must submit an application for PIP benefits. No claim can be paid without this form. A thorough exam (complete diagnosis, treatment plan, prognosis) should accompany first bills. Adjusters: Accept applications for benefits, even if your company logo does not appear. Remember, claims are payable within 30 days.
Minimize litigation by keeping patients/insureds happy. Doctors: Communicate with your patients and be sure they have complied with the insurer's requests for forms/information. Adjusters: Communicate with doctors and patients when problems are encountered.
Independent Medical Exams
While IMEs are a necessary evil, their need can be reduced and made less traumatic. Communication between the insurance company, the treating doctor and the patient will minimize the need for an IME. Good documentation (SOAP notes) will go a long way in eliminating the need for IMEs. Poor communication from the doctor results in uncertainty for the adjuster, which translates into "automatic" IMEs.
All insurers reported a need for a wider pool of doctors willing to do IMEs, citing this reluctance was behind the repeated use of a few doctors.
Insurers emphasized that IMEs are done on all providers' patients -- not just chiropractic patients. Doctors: Please see item one under "Communications."
IME doctors should communicate with the treating doctor before the examination. Treating doctors should send copies of their notes to the IME doctor prior to the exam so that the IME doctor is fully informed of the patient's condition.
Managed Care
Current managed care systems do not have enough patients to warrant adding providers to their panels. Doctors were urged to make their applications to managed care companies. Managed care organizations (MCOs) begin with existing applications when seeking to add new providers.
Providers often see the "provider profile" as a threat to keep them in line. According to MCOs, treatment parameters are developed through aggregation of individual provider profiles, not arbitrarily. All parties agreed that it is difficult to resolve the quality of care/cost-containment paradox in managed care, however, representatives of insurers and MCOs felt this was not an issue in their own companies. Doctors expressed a need to know the rules before agreeing to work within the parameters of managed care: the termination criteria, the treatment parameters, and the documentation requirements. All parties agree that managed care in PIP cases appears to minimize litigation
Documentation and Coding
It was generally agreed that good documentation was the cornerstone of the patient/doctor/insurer relationship, beginning with a thorough history, including past injuries or accidents. A complete examination, diagnosis, prognosis, and treatment plan should be submitted to the insurance company as early as possible. Insurers want to know length of treatment and the expected time of dismissal. Insurers found terms like "guarded prognosis" as smokescreens that raised red flags. Daily notes, updates in the prognosis and treatment plan were especially valuable to adjusters in helping them understand the case. Insurers expressed frustration with doctors who refused or were unwilling to submit notes, the implication being that doctors did not want to tell the whole story.
Treatment Guidelines
"It's the treatment plan, not the guidelines," was the succinct summation of this roundtable. Insurers wanted to know what to expect with a patient's progress; assurance that treatment is goal-oriented; that changes in approach or provider would be made if insufficient progress occurred. Guidelines were seen as benchmarks, not as absolutes.
Treatment Outcomes: What Really Works?
Insurers wanted a clear, objective definition of both the patient's condition and treatment goals. Doctors wanted to ensure that the patient recovered as fully as possible. Arriving at a common definition for success of treatment outcomes is the crux of the problem, unfortunately no single authority exists to render this definition.
Rehabilitation
The goal of any rehabilitation program is for a patient's full recovery. There was some confusion from DCs and adjusters on the different roles of physical therapy and rehabilitation. Because rehabilitation is paid under a different portion of the PIP statute, it's important for documentation to accurately reflect the patient's condition, the need for rehabilitation, the procedures, and the goals. Rehabilitation is appropriate for chronic problems only and should not be undertaken with acute or subacute patients. Often insurers will pay for health club memberships under the assumption the patients will comply with their doctor's recommendations, but compliance under these conditions is rare and additional treatment costs may arise in the future because the patient's full function was not fully restored.
Cost Containment
Both groups agreed that it's the responsibility of the treating doctor to be efficient and effective. Communication between insurers and providers was seen as central to successful cost containment. Patients should understand that they too have a responsibility for keeping costs of treatment low and should need to comply with treatment recommendations and insurers' requests. It's the responsibility of the doctor/insurer to make certain the patient understands these requirements. Since lost wages consume an ever-increasing amount of insurance claims dollars, it's vital to get the patient back to work expeditiously.
As paperwork is time consuming and costly, insurers should request only the amount of documentation actually needed to process a claim and should read and use all information submitted. Doctors can minimize additional paperwork by submitting full information initially.
Darcy McKinstry, executive director
Colorado Chiropractic Association
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