Blog, Live Events May 6, 2024

Chiropractic Malpractice Insurance – What Is Medical Necessity?

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Greetings, everyone. This is Sam Collins, your coding and billing expert for chiropractic, ChiroSecure, and of course our profession. One of the questions I get, because I write articles, I’m out lecturing, and in dynamic chiropractic, one of the big issues I’ve had recently is What is medical necessity? How do we define it?

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What does it mean? Where does it come from? Who determines it? What makes a difference? Let’s talk a little bit about that. Let’s go to the slides. Let’s really get into What would be chiropractic medical necessity? What defines the need for care? Who is defining this really? I would say first and foremost, it’s always going to be the patient.

The patient is going to define what’s medically necessary. Does it make them feel better? Is it helpful? At the end of the day, who else is going to decide what’s medically necessary? Of course, you as the provider, you have a certain determination of the necessity of care, what the purpose is.

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And of course, there’s always in the background who’s paying for it. In this case, let’s talk about insurance. How does insurance define it? What is different about it? Is there things about it that are unique or different that allow it to be payable, not payable? As you’re all aware, medical necessity often can be one of the biggest issues for chiropractors because chiropractic feels good.

People feel better even when they don’t feel bad. It’s like saying medical necessity for health. Wait, Medical Necessity for Health. Hold on, we use the term health insurance, don’t we? But is it really? Or is insurance sick insurance? And I think there’s the difference of how do we define medical necessity?

Let’s start first start with How does a patient determine if something’s medically necessary? At the end of the day, does it make them feel better? Does a patient go, wow, this is something I like. There’s something that has value. And I think that’s really the determination. Medical necessity comes down to the value of the service.

And for a patient, the value is how does it make them feel? This is why so often, Patients for chiropractic care will pay cash because they’re not worried about insurance. They know the service makes them feel better, so therefore there’s that value. But I will highlight something. There has to be value.

And this is something my mom always told me that stuck to be true. And even more so now that I do this part of the profession, people will buy what they want and beg for what they need. I want you to think about that for a second, buy what they want. You ever have someone borrow money from you to pay rent?

But then they haven’t paid you back. And then the next month they’re wearing some brand new shoes. And you’re thinking, wait, how’d you buy new shoes? You haven’t paid me back. They wanted the shoes in a sense. People want the care. They’ll pay for it if they need it. Oh, wait a minute. That’s where insurance comes in.

So do create always a sense of value because patients put value to it. Have you created that sense of value? Can they see it? See the difference of what you’re doing. At the end of the day, what does that mean for a patient? It’s cash. But it could even be co pays, deductibles, and so forth. So medical necessity from that standpoint, always think, what is the patient thinking?

What is the value of what I’m getting? How is this enhancing? And does the value equate to what the cost is? And setting yourself up in that way. At the end of the day, it’s going to be cash or insurance from a patient. And how they determine necessity is going to be dependent upon how’s it being paid.

Obviously, if insurance covers everything, maybe they’re a little less than necessary. We’ll be careful there. But when they’re paying cash, they see the value. So it’s always creating a value response for necessity. What about the chiropractor? How does a chiropractor see it? Based on philosophy, obviously you’re gonna have, there’s got to be a subluxation or a dysfunction.

There’s pain and there’s gonna be functional change or loss of functional change. So the idea is medical necessity happens when there’s subluxation. Resultant pain or dysfunction, and then the ability to make the patient better. What are we doing with necessity? Making the patient better, but what is that defined as?

What do we mean by better? Does better mean I sleep better, I feel better, I have a better mood, or is it only about I have less pain? With insurance, that’s where things get a little trickier. How does insurance determine it? And how do we meld these? Do they ever really become congruent? Insurance says this and this is taken directly and I’ve used a conglomerate here of Medicare and other health insurances But it says a patient requires treatments by means of manual manipulation.

That’s what chiropractors do Of course We expect that manipulation has got to be part of the care and there must be some type of direct Relationship between the services and the outcome and there’s a reasonable expectation of recovery or improvement so medical necessity from an insurance is Chiropractors are doing what you do, meaning adjusting, and the patient is getting better.

But notice so far, no one’s talked about it being pain. As much as we talk about that, pain by itself is not enough. There’s got to be some loss of function. What if you had a person that says, My back is killing me, but it doesn’t stop me from doing anything. That doesn’t sound about right, does it?

If the back is killing them, they’re gonna have an inability to do something. So focus more on the function. So it says here, and this is from Aetna, if there’s no improvement within the first two weeks, additional treatment is not considered medically necessary. So what is medical necessity for them?

Improvement. Improvement and pain reduction, I think, is part of it, but then function. It says, though, if there’s no improvement within two weeks, it’s got to be modified. And of course, that means you change the care plan. There’s something unique that you might be doing that will be better. Ultimately, though, if it’s not within 30 days, they’re going to say not medically necessary, or treatment is also considered not medically necessary once the therapeutic benefit has been achieved, once it’s plateaued.

There becomes the difficulty for most chiropractors in defining medical necessity because Who wouldn’t find medically necessity to keep a person feeling healthy? I find it interesting that when we deal with medication, it’s often always maintenance. You think about it. If you take blood pressure medication, does it cure the problem?

No, it maintains it. So therefore what’s the purpose if it’s not going to cure it? And I think that’s often where it’s misguided. And I think hopefully we’ll get some changes where they start to realize maybe it’s cheaper and better to keep a person healthy in the first place. And so at the end of the day, start to think of how is the person who’s defining it looking at it.

Am I defining it for just yourselves? Am I defining it for the carrier? Am I defining it for the patient? And there’s really going to be some achievement there with both. But ultimately, be careful of maintenance. And while I believe in maintenance care, is it paid by insurance? It says maintenance therapy includes services that seek to prevent disease, promote health, and prolong and enhance the quality of life.

Doggone, I think that’s maybe one of the best things we can do. But it says, When further clinical improvement cannot reasonably be expected to form a continuous, from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is considered maintenance.

Is there a value there, though? Are more people beginning to understand it’s better to stay healthy? Why do we eat healthy food? Why do people exercise? That’s just to maintain. Isn’t that the purpose often? And therein lies the difference of having a practice that depends not only on one source of patient or revenue, but cash and some insurance, just not all, of course, because medical necessity at the end of the day is defined by the patient, and are they getting better?

And whether the insurance is going to cover it potentially, you can bridge that because if the patient finds enough value in your care, then it’s medically necessary. Medical necessity is what you set up a patient to understand and then can define, if you will, for an insurance. How do we define it, though?

What you really want to think of, most people, when they have something wrong, what do they feel? Pain. Show me that their pain is less. Patients can define that pretty easy. But then also functional improvement. In fact, it says here, by clinically meaningful improvement on validated disease specific instruments.

Meaning, Oswestry’s, Disability Indexes, General Pain Index, any of those that you’ve demonstrated, I think it’s easy to see. It’s like a scale. If you’re showing a person’s losing weight, there’s got to be some type of measurement. Is it their weight on a scale or is it the measurement of their hips?

Either way, it’s defined with something that’s tangible. At the end of the day also, remember, any decrease in pain medication has got to be helpful, or any medication for that matter. And then of course, objective measures demonstrate the extent of meaningful improvement. It’s very important to always be able to demonstrate it.

Think of often, when you’re in pain, What you’re doing with a patient is demonstrating, look what you have an ability to do now that you couldn’t do before. That’s what insurance carriers look at, but how do we define that in our notes? Because it has to go beyond the patient’s understanding. So it means something documented at the end of the day.

And keep in mind, necessity can be difficult because there are lots of things. that prevent a patient from getting better. All types of complicating factors. The person’s job, their lifestyle. What about underlying spondylosis, curvature changes? All those things make a difference in defining, but ultimately, not that it’s not defining that it’s necessary, but that it may take longer or take more intense care.

At the end of the day, your job is to help people. And when you do it well, people are willing to pay. Patients and insurance. I want you to go out and be that good chiropractor. The one that delves into this issue by working it on both ends. Ultimately, not always depending upon insurance, but also getting a patient with a good understanding.

As always, this is Sam Collins from H. J. Ross. We’re always here to help. Please go out and do a good job and if you need some help with coding, billing, documentation, anything of that nature, just give me a call. We’re ready to go. Take care, everyone.

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