I hear this all of the time. This is because most chiropractic offices’ sense of case management revolves around the statistic known as RETENTION. The more the doctors can increase their retention statistics, the more income they will gather. Well, that is fine and good but, if my mother, sister, or grandmother were to see a chiropractor and they recommended a sixty-visit plan on the second day during their report of findings and told them to pre-pay for care, I would tell them to run for the hills, because this is what some management consultant told them to say and tells the same story to every new patient that walks in the door.
There is absolutely no way of knowing for certain that any particular patient needs that many visits from the first visit—on the other hand, maybe they need more than sixty visits?
Do you see what I am getting at here? We, in the chiropractic profession, have let practice management gurus all over the country run the case management strategies for our practices, because we have no idea how to use case management effectively when we graduate from school.
Now I want to let you know that there are a handful of practice management people which teach proper case management strategies that will get you paid better and faster–strategies such as those I will outline in this article. My advice: Keep looking till you find those people.
Another reason that I know that we are poor case managers is because the insurance industry only wants to pay for twelve to fifteen visits or six weeks’ worth of care. This is because most offices provide no clinically objective evidence to support the need for care beyond that. This is why documents like the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) have been created. The insurance industry wants to have a set of guidelines to use to deal out care in an appropriate manner. The only problem with the CCGPP guidelines is that it is wrought with bias, gives a substandard level of care to patients and provides no direction to practitioners on appropriate levels of frequency and duration of care based on the patient’s health history and present condition. The MERCY document was created for this purpose for low back pain but was refuted by a good portion of the profession. The Council on Chiropractic Practice guidelines have also been developed and they are the only chiropractic guidelines registered on the National Guidelines Clearinghouse (NGC). It is the position of the Guideline Panel that individual differences in each patient and the unique circumstances of each clinical encounter preclude the formulation of “cookbook” recommendations for frequency and duration of care. (Chapter 7, pg. 84) The CCP Guideline states that a chiropractor must adjust a subluxation until all indicators of subluxation are gone. (Chapter 7, pg. 84) These are the only guidelines that are available for the chiropractic profession at present that can be used for the entire spine and are actually fair for all concerned: the doctor, the insurance company and, most importantly, the patient.
The words maximum medical improvement are foreign words to us. In fact, these words create anxiety in most chiropractic offices, because these words are synonymous with, “The insurance company doesn’t want to pay me.” Maximum medical improvement is defined as when a patient has improved to the point where their physical functioning is normal or when the patient has plateaued in their improvement over several reexaminations.
The definition of maximum medical improvement includes words such as functioning, not pain. The insurance industry is not interested in treating the patient for pain; it is a given that you are going to get the patient out of pain. The insurance industry is more interested in getting the patient back to normal function or as close to it as possible, given the patient’s present health condition. The definition of medical necessity creates just as much anxiety only because the definition is dependant on the insurance company itself. But there is a common denominator in nearly all definitions and that is FUNCTION.
Medicare Policy on Medical Necessity
A treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or a therapy that is performed to maintain prevent deterioration of a chronic condition is not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.
Bluecross/Blueshield Policy on Medical Necessity
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 an ongoing, written treatment plan.The Council on Chiropractic Practice guidelines state that, “The appropriateness of chiropractic care should be determined by objective indicators of vertebral subluxation” (Chapter 7, Pg 84) and further states that, “Since the duration of care for correction of a vertebral subluxation is patient specific, frequency of visits should be based upon the reduction and eventual resolution of indicators of the subluxation.” (Chapter 7, pg. 83)
Therefore, based on the fact that we need to provide objective evidence that the patient has a loss of function and that we need to provide more evidence that we are improving that function to the extent the patient is now functioning normal or has plateaued over several reexaminations, I propose a case management strategy such as the one illustrated in Table 1. (See Pg. 48)
Initial Visit- Questionnaire(s), Examination, X-rays, Therapeutic Modalities (3)
Second Visit- cROM Testing, CMT, Therapeutic Modalities
Third Visit- cMT, CMT, Therapeutic Modalities
Fourth Visit- PPT testing, CMT, Therapeutic Modalities (3)
Fifth Visit- CMT, Therapeutic Modalities
Sixth Visit- CMT, Therapeutic Modalities
Seventh Visit- CMT, Therapeutic Modalities
Eighth Visit- CMT, Therapeutic Modalities
Ninth Visit- CMT, Therapeutic Modalities
Tenth Visit- CMT, Therapeutic Modalities
Eleventh Visit- CMT, Therapeutic Modalities
Twelfth Visit- Re-Exam, Questionnaire(s), CMT, Rehabilitation
Thirteenth Visit- cROM Testing, CMT, Rehabilitation
Fourteenth Visit- cMT, CMT, Rehabilitation
Fifteenth Visit- PPT testing, CMT, Rehabilitation
Sixteenth Visit- Rehabilitation, CMT
As you can see, there are several diagnostic tests at the beginning of care that need to be performed: X-rays, computerized ROM testing (cROM), computerized muscle testing (cMT), pain pressure threshold testing (PPT) and questionnaires. These cROM, cMT, PPT testing, questionnaires, and X-rays are all diagnostic tests that take the patient’s subjective symptoms and place them in an objective format so that you, the doctor, can re-test the patient using the same tests and objectively determine whether or not the patient has improved, not improved, or regressed.
Table 2 is a list of subjective signs and/or symptoms and the list of diagnostic tests that the doctor of chiropractic would use to evaluate those signs and/or symptoms: (See table 2)
Questionnaires (Oswestry, Neck Pain, Roland Morris, VAS, Headaches Disability Index), Pain Pressure Threshold Testing)
Numb/Tingling/Burning Pain NCV testing, EMG testing, DSEP Testing
Disc Lesions MRI
Fractures CT, Radiographs
Loss of Range of Motion cROM testing
Loss of Strength cMT Testing
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 [email protected]