Red Flags in Chiropractic Claims

Employees are entitled to receive reasonable and necessary medical care related to their work injury. Problems arise when they start receiving medical care and treatment with a chiropractor, and it becomes excessive. Proactive claim handlers can be engaged in files involving chiropractic care, identify red flags, and take steps before this treatment modality is out of control.

Red Flag #1: Lacks Evidence of a Reasonable Treatment Plan

The goal of any form of medical care is to restore the employee to their pre-injury status. The problem with chiropractic care in some instances is the care does not have a defined treatment plan. As is the case with any treatment modality, the chiropractor providing medical care should define short term and long-term goals:

• Short term: The plan should define what care will be provided to the employee to reduce pain and restore normal muscle and joint function.
• Long term: This portion of the plan should define how the care will allow the employee functional independence and perform everyday activities of daily living.

As is the case with any form of medical care, it should never be a goal of requiring the employee to receive chiropractic care for the rest of their life. This is palliative in nature and exceeds the goal of care to cure and relieve the effects of the work injury.

Red Flag #2: Care Provided Lacks Documentation and Details

A common objection to medical care provided by chiropractors is that it consists of page after page of the same care – the provider is merely using the copy/paste functions on a word processor. Claim handlers need to scrutinize these medical records and be proactive when they receive medical records that document the same complaints, same treatment, and same recommendations.

Red Flag #3: Frequency of Medical Care

It is common with any treatment modality that the initial medical care is provided consistently. For example, someone will likely receive medical care three days a week – the same three days every week. Other examples include instances where the employee receives care at a chiropractic clinic that shares a common entry with a physical therapist. Determine if they are receiving care at both providers on the same date.

When reviewing chiropractic records, it is vital to see if the frequency of medical care is provided according to the treatment plan and that the frequency diminishes over the course of time. Objections need to be raised immediately if the care is provided with the same frequency week after week – month after month.

Red Flag #4: Lack of Pain Relief

All medical care provided under the workers’ compensation system needs to provide pain relief and improve functionality. When reviewing chiropractic records, it is essential to note what relief is provided with the care. Another critical component for review is the length of the relief. Areas of concern can include unexplained exacerbations during phases in medical care when the employee has documented improvement in symptoms. Questions can be raised at deposition or recorded statements about these instances.

Red Flag #5: Duration of Treatment

Common problems with chiropractic care are excessive medical care. Examples of this include:

• A well-documented history of prior “maintenance care” before a work injury that results in the same ongoing care following an injury; and
• Never-ending chiropractic care following a work injury.

Proactive claim handlers and defense attorneys need to be on guard for this excessive medical care. Information to ascertain where the care is excessive can be found through discovery tools. It is important to obtain medical records from all prior chiropractic clinics. Scrutinize the details of these records to determine if there are references to other periods of care at these same types of facilities. It is essential to quiz the employee about this type of care at a deposition.

Red Flag #6: Costs

Review all chiropractic bills related to the cost of care. Rely on an applicable medical fee schedule. If a schedule is not available, determine if cheaper alternatives are available to bolster arguments about the reasonableness of care.

Conclusions

Interested stakeholders and claim handlers need to be proactive when it comes to the cost of chiropractic care. Pay attention to the details in the medical record and billing statements to determine whether the care provided provides relief or enriches the medical provider. Taking these steps can reduce workers’ compensation program costs and position claims for settlement.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.

Contact: [email protected].

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