Challenges to PIP Payments

We have noticed an increasing number of challenges to personal injury protection (PIP) payments by use of mere medical records reviewing companies. These companies are sometimes based in Arizona, Las Vegas, Florida or other places. They often hire individuals who purport to be DC’s or MD’s who, for a price, supposedly review the records produced by the treating DC and then write a report. The report usually determines that the volume of care is insufficiently documented and/or was unnecessary due to improper or insufficient diagnostic coding. Often, the reviewing agency will also suggest that the prices for the individually CPT-coded treatment modalities exceeds the “usual and customary” rate for such services. Many times we have seen no reference to the Relative Value Study in such a conclusion. When you discover one of these efforts being used to decline payment of Personal Injury Protection benefits, there are several things you need to remember.

First, remember that although the Utah Chiropractic Physicians Association has determined that paper reviewing is unethical, such an objection will not guarantee that the practice will either be stopped or used to allow the court to block the admissibility of the records reviewing physician from testifying in court. Rarely are these physicians members of the UCPA or licensed in Utah. Such lack of licensure and the fact that such practice might be unethical may go to the weight to be given to the testimony and used as a means of impeaching the value of such physician’s testimony. However, most judges will still allow the jury to hear the testimony if the matter were to be tried before a court. Most insurance companies know that these matters rarely go to court, and they are simply using the records reviewing position as a means of avoiding an allegation of bad faith against the insurance company itself. Under case law in Utah, bad faith does not exist if there is even a “fairly debatable” challenge to the actions of the insurance company. If the insurance company can rely upon the testimony of another “expert” to suggest that the care was unnecessary or unreasonable, then they have created a question of fact which they can use to say that the argument was at least “fairly debatable.”

Second, if you are unaware that Section 31A-22-307(2) UCA establishes the Relative Value Study as a means of determining the reasonableness of charge, then you will not be able to effectively battle with an insurance company’s allegation of unreasonableness. Get familiar with that code section and use the Relative Value Study to establish the prices for the codes you are charging.

Third, the biggest argument that most of these records review physicians use is the lack of sufficient documentation. Look at the following paragraph which was taken directly from one such reviewer’s letter:

The patient is a 31 year old female born on 10/27/80 and involved in a motor vehicle accident on October 22, 2011. She has been diagnosed with cervical and thoracic sprain/strain with lumbar and rib segmental dysfunction. Relevant objective findings are unremarkable.

The records have been provided and 67 pages were reviewed. I fee that treatment rendered is excessive. I feel that this injury does not warrant treatment beyond the initial 12 visits. The casual relationship is developed through daily chart notes. The patient stated that she was treated previously in this office, however there were no records to review. The daily chart notes do not contain sufficient objective documentation to support medical necessity for all care rendered to the patient. Treatments on the dates of service in question are not documented as medically necessary. The chiropractic treatment records in this case are quite abbreviated and provide little clinical information. To be considered medically necessary and to support continuation of the treatment plan, the clinical records should demonstrate progressive subjective and measurable objective improvement, with functional gains. Furthermore, the authoritative guidelines call for an interim exam to be performed every 12 visits or 30 days to develop medical necessity. To date and 2 months post injury, there have been no interim exams submitted nor any documented in the billing. These exams would include: orthopedic testing, neurologic testing that includes reflex, motor and sensation testing, nor range of motion testing. With proper interim exams the doctor can monitor progress and design a revised treatment plan. There are no positive orthopedic tests or neurological findings discussed. There are no continuing values for range of motion. I therefore feel that the date of service (12/30/11) with the accompanying CPT codes (98941, 97110, 97140, and 97035) is not medically necessary.

Is the above language really asking too much? Most physicians already do exactly what this records reviewing physician is asking to be done. If you are not doing this approach and are merely using SOAP notes to document your patient’s condition and progress, then you are asking for trouble and when you find it, will not be able to find it to defend yourself or justify your care very effectively. A far stronger approach is simply to improve the quality of your documentation. It really isn’t that difficult. Now, by my suggestion that the above records reviewing physician has a point doesn’t mean to suggest that I like or agree with what they do. These record reviewing “IME” physicians are merely wolves who are trying to prey upon the weakest of the herd. If your records make you look like you are weak, then you will be much more likely to have your billings challenged and your cash flow interrupted.