The Mercy Guidelines -- Now It Begins!

I was sitting in my office on a wintry Friday afternoon, the outside temperature in the mid-20s, and feeling rather bleak, when I received a fax from Bill Remling, DC, of the New York Chiropractic Council, the organization which my firm represents. The fax was a letter from The Travelers Insurance Company refusing to pay for a diagnostic test, the surface EMG, and citing the Mercy Guidelines as the reason.

The exact text of the letter was "The Travelers has adopted the standard based upon recommendations of the Mercy Conference which encompasses the standards of practice of chiropractic care. The adopted standard is that kinesiologic surface (scanning EMG) has not been shown effective. This procedure generally remains investigative; and is not considered medically necessary for the diagnosis and treatment of an illness or injury."

The effect of this letter got me going and I was no longer concerned about the outside weather conditions, but rather that a major medical carrier is taking the Mercy Guidelines and using it to their own ends.

An analysis of the wording of the letter shows that the carrier has totally misinterpreted the Guidelines, and has classified them as standards of care, which they are not! Additionally, the carrier picks and chooses the language it likes and utilizes this to deny a claim. They failed to note that there are times when the use of the SEMG is promising, and, as such, is reimbursable in the clinical practice.

I responded to The Travelers and brought a few things to their attention:

1. The Mercy Guidelines have an effective date of July 1, 1993, and they were relying upon a document that is not in effect.

    

2. The Mercy Guidelines are not a "standard of care."

    

3. The document is "advisory in nature."

    

4. The document is not to be used as a sole basis for the evaluation of claims.

    

5. The practitioner is the ultimate judge as to the propriety of treatment and care rendered to a patient.

I don't know how, or if, The Travelers will respond to my letter, but I do know that I am prepared to litigate against any carrier which utilizes the Mercy Guidelines solely as a claim denial device.

James K. Hogan, Esq.
Patchogue, New York