Chirpractors, Insurers Mending Claims Handling Disagreements

Insurance claim handlers and chiropractic doctors are engaged in talks to open communication and avoid protracted legal
appeals and high-end claim costs, according to experts from the insurance and chiropractic industries.

At the National Association of Independent Insurers’ (NAII) Fall
Legislative Meeting, members of the insurance and chiropractic professions spoke about progress made during the past four years to resolve labor-intensive and expensive claim handling issues involving chiropractic claims.

Beginning in 1999, chiropractors and insurers have had formal
discussions leading to problem solving initiatives and improvements through the development of public policy and education materials useful to internal policy makers, claims adjusters and medical review personnel in understanding chiropractic care and acceptable billing and documentation practices. Curbing fraudulent claims also have been addressed.

“The American Chiropractic Association has developed important resources with input from national and regional insurers that seek to bridge the communication gap between the insurance and chiropractic professions,” said Gary Cuneo, ACA executive vice president.

Representatives from both professions have reportedly worked together to establish basic, standard clinical documentation requirements in patient record keeping to improve the reimbursement process. As a result, the ACA Board of Governors has approved an official policy statement manual regarding national medical documentation standards and a comprehensive program about proper treatment.

A Claim Adjuster Index education site also has been launched, which informs claims adjusters about chiropractic care and treatment and attempts to reduce medical review expenses on chiropractic claims. The index is available on the ACA Web site at:
http://www.acatoday.com/insurance/p_a_education/.

“It’s always been us versus them – insurers versus the chiropractic
profession,” Richard Wisniewski, vice president and manager of the medical management department for Erie Insurance Group, said. “Before the two professions began an open dialogue, claims were ending up in litigation most of the time and incurring additional costs and time. It affected the patients because claims were not being settled and treatments were being delayed or not administered at all.”

Wisniewski said the development of guidelines that address the expected length and type of treatment per ailment and discussing the reasons and causes for increasing costs have helped to ease common insurer gripes about abuse, diagnostic testing, coding, medical documentation and other issues.

Similarly, chiropractors had reportedly been complaining about insurer medical reviews, timeliness of payments and medical documentation needs, but the ongoing meetings have helped address some of those concerns, according to Wisniewski.

“Chiropractors have felt left out of the process in addressing costs and service when it comes to managed care access,” Wisniewski said. “We ask insurers to get the message out to your claim handlers to keep the lines of communication open.”

“We have worked hard to address the issue of best practices for the
claims handling policies process,” Cuneo added. “We implore insurers in local and regional offices to communicate with claims managers who are on the front lines. We have come together to make a difference. We understand we need to work together to avoid protracted appeals and high-end claim costs.”

When asked about states placing caps on the number of treatments and visits, both Cuneo and Wisniewski agreed that such limits are not viable solutions for the perceived “over-utilization of treatment” issue.

“Over-utilization (of chiropractic care) is not a wide-spread problem,”
Cuneo said. “Only a few bad apples -practitioners – exist out there that are running up costs. It isn’t fair to penalize the whole profession. Any mandates should be a ‘reasonable’ control so that the good guys don’t end up being hurt.”

Wisniewski said legislation on limits for visits and treatment is more
of a “target” rather than a method to manage costs.

“Everyone heals differently, which is why it is very important for
insurers to have access to medical records,” Wisniewski added.