It is crucial that those involved in clinical case management, both in the hospital and the insurance industry, be familiar with the appropriateness and indications for chiropractic care in the hospital setting. In 1987, the American College of Surgeons published a position paper that approved of the association with chiropractors in the hospital setting. Their statement read, in part, as follows:
The provision of treatment privileges and diagnostic services in or through hospital facilities; working with and cooperating with doctors of chiropractic in hospital settings where the hospital's governing board, acting in accordance with applicable law and that hospital's standards, elects to provide privileges or services to doctors of chiropractic; association and cooperation in hospital training programs for students in chiropractic colleges under suitable guidelines arrived at by the hospital and chiropractic college authorities; participation in student exchange programs between chiropractic and medical colleges.1
In my six-plus years of being on-call in the hospital emergency department (ED), I have seen numerous ED physicians gain familiarity with the indications for chiropractic consultation. I have enjoyed seeing the attending physicians learn to appreciate the role of the chiropractor in the ED. Even more enjoyable is witnessing the ED physician's growing dependence on their staff of chiropractors.
On occasion, I have been required to explain the necessity of chiropractic care to an insurance company representative so they could appreciate the benefits as well. Most insurance and review professionals are much more familiar with chiropractic as an office-based, "rehabilitation" type of service. The hospital serving as a place for chiropractic procedure does not always fit into insurance company or review organization algorithms or reimbursement guidelines. Chiropractic services provided in the hospital are primarily an emergency service. There is no time to pre-certify emergency care and there is no treatment plan beyond the initial visit. Insurance professionals who are very familiar with chiropractic may have no knowledge of chiropractic provided as an emergency service in the hospital setting.
The following case history illustrates an example of an ED patient whose insurance company denied reimbursement until receiving further explanation. As you will read, there was no logical reason to deny care. The denial was obviously due to unfamiliarity, a computer programming difficulty, or simply failure of the claim to fit within historical parameters for chiropractic claims. Fortunately, once aware of the nature of the claim, the insurance representative quickly reversed the previous denial.
This case involved a woman suffering from a severe and disabling headache. The attending ED physician evaluated her condition. She discovered that the patient had a long history of migraine headaches, for which she had been under the care of a neurologist. For the past week, the patient had suffered progressively worse headaches that were not relieved by numerous prescriptions or over-the-counter medications. The ED attending physician had to consider co-morbidities and other risk factors, including the patient's history of a previous CVA. After obtaining the appropriate imaging studies, the attending diagnosed the patient as suffering from migraine with cervical tension cephalgia characteristics. The patient had already self-medicated with Imitrex at home. The attending first ordered administration of Toradol, a potent nonsteroidal anti-inflammatory drug. When Toradol did not relieve the patient, the attending ordered Demerol, a strong narcotic analgesic. When Demerol failed to provide relief, the attending had to consider additional treatment options.
It was the attending physician's opinion, as the ultimate authority in the emergency department setting, that it was not in the patient's best interest to re-medicate or to administer additional narcotic analgesia. The attending physician weighed the risks and benefits of the available treatments and decided that chiropractic care for emergency pain relief offered the best alternative for this patient. At 11:30 p.m., I answered the call to consult with the patient in the ED. I found the woman in bed, with the lights off. She complained of excruciating pain that had not been relieved by the medication she had taken at home or that had been administered in the hospital. Keeping her eyes closed, she complained that she could not imagine herself attempting to leave the hospital in her current condition.
Examination findings of particular importance included the presence of cervical hypertonicity, suboccipital tenderness and cervical vertebral joint fixation. She responded well to treatment with ischemic compression, peripheral neurofacilitation and spinal manipulation. She reported significant relief from the chiropractic treatment. She improved sufficiently to allow for discharge. She avoided admission for intravenous analgesic narcotics and the need for other specialist consultation. I returned home at approximately 2:00 a.m.
It was surprising to obtain a denial for my services from the insurance company. The denial related only to the location of services: chiropractic provided in the hospital setting. I had previously received reimbursement for similar treatment provided in the office or a patient's home. I imagine I would have received reimbursement for providing similar services on a park bench. Unfortunately, placing the code for hospital as the place of service on the billing form creates a mismatch in the insurance computer.
As I explained to the insurance representative, this patient did not respond to several types of medication. As per the federal EMTALA regulation, she was considered unstable due to her continued severe pain, and it would have been improper and illegal to discharge her to go home. In accordance with the federal ERISA guidelines, the attending physician was responsible for determining that the patient's level of pain was severe enough to constitute an emergency. Also per ERISA, reimbursement for care cannot be denied without a detailed explanation.
All have to agree that the attending physician benefited by having the ability to call a chiropractor as chiropractic care helped the attending resolve the patient's complicated condition without hospitalization or the risks of additional medication. The attending was able to more quickly free up an emergency department bed, as patients who are being admitted from the ED frequently have to wait until there is an available bed on one of the floors. The hospital benefited by improved reputation. You can imagine how this patient must have told her friends and relatives how the hospital staff went as far as calling in a chiropractor when all other treatment failed. The insurance company benefited by not having to pay for inpatient hospitalization and numerous specialist consultations and diagnostic tests. The benefit to the patient is obvious. Her pain improved and she was able to return home. The only neglected person was the chiropractor who provided the needed care.
Insurance company policy-makers need to be aware of how chiropractors can improve the care for their policy-holders while decreasing costs. Our chiropractic department is in its sixth year of providing on-call chiropractic services for our hospital's ED. We have increased patient satisfaction and freed up valuable human and facility resources for other patients. We have reduced re-medication, the need for narcotic analgesia, repeat visits to the ER for the same complaint, and most importantly, hospitalization for IV narcotic analgesia of neck and back pain.
While chiropractors have been improving care for the patient, improving the image of the hospital and saving money for insurance companies, a small number of insurance companies and chiropractic review organizations have yet to become familiar with the benefits of chiropractic treatment in the ED setting.
The American College of Surgeons published a policy approving chiropractors in the hospital setting. Medical physicians who work with chiropractors in the ED have learned how to use the chiropractors as a tool to offer the best treatment to their patients. Insurance carriers and review organizations need to create appropriate policies regarding chiropractic services provided in hospitals. The companies need to start by altering the reimbursement computer programs to prevent automatic denials of claims that contain chiropractic treatment codes associated with the hospital as the place of service. I have worked with insurance carriers and review organizations to adopt these changes. I welcome the opportunity to assist others in adopting appropriate policies and procedures for handling chiropractic claims generated in the hospital setting.
Reference
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