A few months ago, I was reviewing a few charts that belonged to a chiropractor under an OIG Fraud investigation, when I stumbled upon the typical problems that plague all chiropractors and their documentation when a third party has requested a review. Flipping through the pages, I realized that the chart’s treatment plan didn’t create an end goal for the patient that could be measured. Oh yes, you could see the ever present 3 to 2 to 1 to cover the requirement for frequency and duration. In addition, the file contained the written goals of "reduce pain and subluxation," but there was nothing anywhere in the file that listed a measurable goal that would create an end point to care that would be paid for by the insurance carrier.
The issue is the difference between a "Care Plan" and a "Treatment Plan"
Then it dawned on me that every patient’s plan of care in the office should be treated based on your patient care philosophy. The doctor’s awareness of their personal style of care, their types of goals for patients and the type of treatment rendered allows for a greater understanding of what and how much will be covered by the insurance carrier by contract. Having this understanding allows the doctor to be able to communicate to the patient what to expect the out of pocket expenses will be, when the patient crosses over from active care to wellness care.
I know for a fact that every doctor who reads the title and the article to this point will say out loud that every case is different and that there is no way you can put everyone into the same care plan. But, I say, that is not true and you should treat every one of your patients with the same care plan.
The issue is the difference between a "Care Plan" and a "Treatment Plan" and this is where most doctors don’t understand how it can leave your past collections exposed to recoupment from the insurance company. Knowing the difference between these two similar documentation components can make a world of difference to the patient, the practice and the carrier.
In a care plan, the doctor will create a road map to what the doctor thinks the patient may need over a period of time to get the result intended. This is no different from laying out full course for the patient to get to a level of "ideal functional wellness" based on the doctor’s style of treatment and philosophy. In contrast, the treatment plan is the legend at the bottom of the map that measures how fast and how far you have gone on your trip. This is where the mistake is made during the documentation process. The doctor stops at this point and does not complete the process to crossover from laying out a care plan to creating a treatment plan. Now, it may be true that you, as the doctor, may want the patient to obtain reduced pain and decreased subluxation as a result of your treatment, but the minimum documentation requirements will mandate the creation of a functional baseline that can create an outcome to prove what you did was necessary. But, remember, the differentiation between a treatment plan and a care plan is that the care plan is created to gauge the patient’s response to measureable goals and other pain related goals are considered subjective or can’t be measured.
This type of distinction is evident in Cigna’s, Aetna’s and Medicare’s guidelines, as it pertains to a measurable functional improvement of the patient’s condition. In fact, over the past 6-12 months, while working to defend chiropractors, we have seen both private insurance and Medicare carriers get tougher on the lack of a treatment plan and totally discount the fact that a care plan was listed. Due to a lack of a treatment plan during a review, the carriers will typically deny care given from the first date of treatment as "not medically necessary," because the required documentation was not correctly created. Making this change will take your documentation farther than you have ever been before, to be able to create medical necessity.
Dr. John Davila is a 1994 graduate of Palmer College of Chiropractic in Davenport, IA, and practiced in the Myrtle Beach, SC, area for 13 years. Since 2000, he has been consulting with insurance companies and doctors in private practice in the areas of coding and documentation. In 2001, he re-wrote the Medicare LCD coverage policy for Palmetto GBA (SC Medicare). His company, Compliant Services & Solutions, Inc., helps doctors of chiropractic to ethically maximize their practices, while avoiding audits and repayments to insurance carriers. You can reach Dr. Davila, toll free, at 1-877-322-6203 or by email at
or on the web at www.ComplaintUSA.com.