The Real Necessity for Diagnostics and Imaging
by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP
You get a letter from the insurance company stating that your utilization of MRI’s is not within their acceptable standards and they give you a warning that you will be excluded from their panel if your referral pattern continues. At first, you are angry, then confused and, finally, you call every friend you have in chiropractic to solicit their opinion. The consensus is that you will now treat the patient for as long as possible, until all else fails, and then consider ordering the MRI, so as to meet the standards of the insurance company. As a result, you have also influenced everyone within your sphere of influence to behave in the same manner.
My personal journey was similar to many of yours; approximately fifteen years ago, I was denied the ability to refer MRI’s to the imaging center, as they were told by the insurance companies that the scans would be denied. The parameters set forth in arbitration, the lowest level of Court in New York State, ruled that an MRI is compensable only if it is deemed an emergency and then must be performed in an emergency room in a hospital, if done prior to six weeks of conservative care.
Armed with this information, I placed two calls: one to the New York State Department of Education, Secretary to the Board of Chiropractic, and the other to the New York State Department of Education, Secretary to the Board of Medicine, as those were the two highest ranking officials in the State of New York that govern over both chiropractic and medical doctors’ licenses. I wanted to get both opinions to make sure the "world was not flat" all of a sudden.
The answers given to me by both were the same: If you suspect that your patient has spinal cord or root pathology, you treat without a conclusive diagnosis and they get hurt, or proper care is delayed, be prepared to lose your license, no matter what the insurance company says. They do not govern the standard of your care. The New York State Department of Education does. Armed with that knowledge, I found an imaging center to work with who would take MRI’s of my patients as long as my documentation was thorough. We prevailed in overturning that ridiculous ruling within a very short amount of time as a result of the documentation and reasonable minds in the courts.
Your standard of care is the same as mine and every other chiropractor’s in the nation. We are governed by our state board’s standard, not the insurance industry and, after a careful review of numerous states, it has been determined that most states have similar standards. The goal of your state board is not to help your practice or to protect you, the chiropractor. The goal is to protect the people of your great state and that is a covenant taken very seriously by all state boards.
The next question is, "What are your standards of utilization of advanced imaging of the spine, specifically, MRI?"
During your clinical evaluation, you would be on very safe ground to order an MRI if there are documented findings of myelopathic and/or radiculopathic findings. The opposition would argue that you should treat the patient conservatively for approximately six weeks to see if those symptoms resolve. That is a very dangerous gamble on your part. What if there is a space occupying lesion and your well intentioned adjustments create further damage? What if there is a tumor and your six weeks’ delay contributed to the metastasis of that tumor? What if, what if…?
Doctors…DO NOT TOUCH YOUR PATIENTS IF YOU DO NOT HAVE A CONCLUSIVE DIAGNOSIS. This is a non-negotiable issue.
Here is the language you use with your patient:
"Mrs. Jones, your evaluation revealed some neurological involvement that I believe a series of adjustments will help. I will give it five to six weeks to respond and, if it doesn’t, I will then consider an MRI to see what’s preventing you from getting well as quickly as I think you should."
Quite eloquent…. However, here is what you are really saying: "Mrs. Jones, I have examined you and have taken X-rays and can’t determine what is wrong with you. I am going to commence with a series of high velocity thrusts into your spine and hope that I have guessed correctly and you do not have a space occupying lesion in your spinal cord or spinal nerve roots. If you do, and I have guessed wrong, you could end up needing surgery that could have been avoided and, in the worst case scenario, you could end up a paraplegic or be diagnosed with cancer that has spread unnecessarily. Let’s get started."
What’s the difference between the first and second explanation? The answer is simple. The second explanation is the truth and the first is eloquent nonsense.
Would a neurologist, neurosurgeon, orthopedic surgeon or oncologist treat their patients without a conclusive diagnosis? The answer is a resounding, "No." We are no different. Simply because the chiropractor does not perform surgery, that does not mean we are exonerated from practicing within the standards of our license. I challenge every chiropractor in the United States to ask their Chiropractic Board if it is acceptable to render care without a conclusive diagnosis.
Do not practice to the standards of the insurance company. Your covenant is between you and your patient.
Dr. Mark Studin is the President of CMCS Management which offers the Lawyers Marketing Program, Family/MD Marketing Program and Compliance Auditing services and can be contacted at www.TeachChiros.com.