Medical Necessity and the Role of Diagnostic Tests
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Written by Dwight Whynot, D.C.   
Wednesday, 18 October 2006 15:43 Read : 1408 times

Was it beneficial for the chiropractic profession to participate in the third party payer system (insurance system) of healthcare?

I believe the answer to that question lies in the consumer perspective. If I don’t hear it today or this week, I will next week: “You know, Doc, ten years ago you weren’t in my benefit package for health insurance. Now I have chiropractic coverage for my whole family. You guys have really moved up.”

That statement is what I frequently hear from new patients. The insurance industry has given the chiropractic profession credibility in the eyes of the consumer. We are not an alternative medicine anymore, but a mainstream primary care profession that caters to the frontline healthcare needs of the public worldwide. 

Many in our profession are frustrated and confused in their attempts at the third-party payer system. Many, many doctors of chiropractic simply just don’t know the rules and understand why it is that they get denial after denial from the insurance companies. The first rule of the insurance industry, and perhaps the most important, is that doctors of chiropractic must document properly and this proper documentation must include the rationale for the care to be deemed “medically necessary.” The most common definition of medical necessity revolves around the patient’s capacity for FUNCTION, NOT a reduction in symptoms. We can take a look at the Blue Shield Association General Policy regarding medical necessity. The policy states:  “Manipulation is a covered service when performed with the expectation of restoring the patient’s level of function which has been lost or reduced by injury or illness. Manipulation should be provided in accordance with ongoing, written treatment plan.”

This statement is the premise by which chiropractors are paid for their services. Virtually all insurance companies (including Medicare) base their medically necessary determination on this functional improvement paradigm and not a pain paradigm.

By utilizing diagnostic tests such as computerized inclinometry, computerized muscle strength testing, computerized algometry, radiographs and outcome assessment questionnaires in the office, chiropractors can provide the OBJECTIVE evidence to the third party-payers that not only is the patient dysfunctional in some capacity, but the care that is being provided to the patient is effective at returning the patient to a more functional status.

Diagnostic tests are used to confirm or deny a diagnosis. So why it is that very few chiropractors utilize them and then ask, “Why did the so-and-so insurance company deny my care?” 

Well, for starters, if all the insurance company had to evaluate and determine medical necessity were the doctors daily chart (SOAP) notes, then the doctor already lost. The daily SOAP notes do not provide evidence for and have never been devised for the purpose of providing medical necessity.  Daily SOAP notes only explain what happened that day, how the patient is feeling or reacting to care, what procedures were performed and what changes in the treatment plan may have happened.  Diagnostic tests are the tools that measure whether or not care is needed and is effective.

Diagnostic tests also provide important data to determine how long active treatment can last. By re-examining the patient periodically with the diagnostic tests mentioned previously, the doctor can chart when the patient has reached maximum functional improvement and can be released from care.  Under this paradigm, the patient is not released when they have no pain, they are released when their functional improvement has either plateaued or has reached full function.

It is especially important to utilize diagnostic tests in a personal injury situation. The doctor of chiropractic must take the patient’s subjective data and make it objective data for a courtroom situation. By using objective data, the judge can give the evidence full weight because it is no longer opinion but, indeed, a fact. If the defense attorney attempts to discredit the objective facts presented, they lose credibility with the jury.

Dr. Dwight C. Whynot is in fulltime practice in Johnson City, Tennessee. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the International Chiropractors Association and sponsored by Myologic and Spinal-logic Diagnostics. For questions regarding evidence-based practice procedures, email questions to This e-mail address is being protected from spambots. You need JavaScript enabled to view it . For 12-hours CCE license renewal lecture dates and places call the ICA at 1-800-423-4690. For more information on Myologic or Spinal-logic, go to www.myologic.com or www.spinallogic.com.


 
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