Medical Necessity Denials for Chiropractors: Solved!
Denials due to a lack of "medical necessity" are a growing problem for chiropractors and often the target of post-payment review audits. Even though carriers appear to be increasingly demanding, getting paid is not an issue for those who can set aside their philosophical beliefs and understand their clinical obligations to prove the value and necessity of their care.
What is "Medical Necessity?
Defining what constitutes medical necessity depends upon which carrier you ask, however most share the view that meeting the standard of medical necessity requires that the chiropractic service performed be "reasonable and necessary" or "appropriate" in light of the patient's condition.
Medicare defines medical necessity as "services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."
Paradoxically, this judgment is rendered by a reviewer who hasn't even seen the patient! This places a significant burden on you to objectively prove the efficacy of your treatment plan. But first you must get past the philosophical challenge.
Crossing the Line Into Maintenance Care
If you're one to use chiropractic care as an ongoing lifestyle adjunct, akin to brushing and flossing and getting adequate rest and exercise, you probably imagine that some type of ongoing chiropractic care would benefit your patients. Which wouldn't be an issue if Medicare or an insurance provider weren't involved. But because they are, you must be fastidious about transitioning patients to paying cash the moment continued functional improvement becomes unlikely.
Acknowledging the limitations of the carrier's obligations and being able to objectively prove it, requires a level of documentation and accountability that many chiropractors simply aren't accustomed to providing. Especially as the patient emerges from the more obviously acute stage of their care. The result? A denial of claims or an audit requesting you return monies that you've already been paid, plus interest.
Prove the Patient Is Making Progress
Avoiding this unhappy outcome begins on the patient's first visit by getting a complete health history. This is where the skimpy, one-page homemade admitting forms fail the typical chiropractor. Not only do they neglect to collect essential information, it's incomplete or so vague that it hamstrings a chiropractor's ability to document the subsequent improvement third parties reasonably expect. In far too many chiropractic practices, the intake form is little more than getting the patient to "do something."
Your obligation is to document each patient's response to your care. An impossible task if you haven't established an adequate baseline at the beginning.
So, not only must the patient have a neuromusculoskeletal condition, your treatment must produce a direct therapeutic relationship to the patient's condition, provide a reasonable expectation of improved function and do so to the satisfaction of someone who hasn't met or even spoken to the patient.
That's why your initial health history intake form must include a way for patients to assess how their condition affects their home and work life. These "activities of daily living" identify the functional goals that form the basis and justification of your treatment plan.
This would include the degree (none, mild, moderate or severe) to which their condition affects their ability to sit, stand, drive a car, use a computer, perform household chores and a variety of other everyday physical tasks. Your SOAP notes must address the patient's progress toward these real-world functional goals.
Submit Claims and Get Paid
Set goals that are objective, quantifiable or functional. Simply put, your treatment will be considered medically necessary when your documentation shows it is making a difference and has a reasonable expectation to continue.
Feel free to unabashedly submit claims to insurance companies for as long as you can prove medical necessity, whether it's for six visits, 20 visits or more. Just remember, that once their clinical status stabilizes, and there is little expectation of further improvement, continued chiropractic care would be considered maintenance care, and in the eyes of an insurance carrier, not medically necessary.