Chiropractor Chart Note Letter to Adjuster "Discounting" Chiropractic Insurance Benefit Billings

 
Your name, D.C.
Name of your practice
Your address
 
February 3, 2005
 
Insurance adjuster's name (be sure to include her title)
Insurance company
Address
 
RE: Your insured and my patient, Robert Johnson
Date of Incident: [Note to D.C.: please insert this line inasmuch as we do want the adjuster to be focused on WHY the patient is there for treatment (i.e., the trauma of the accident), as opposed to some general ache or pain he picked up lifting things in the garden or at work.]
 
 
Dear (insert name of adjuster)
 
I am writing at the request of Mr. Johnson to provide information regarding his care at my clinic. According to Robert, you notified him that you would pay only a portion of the charges he incurred during his treatment here. I offer no comment on your decision inasmuch as my profession is concerned with healing, not fair application of insurance laws.
 
Therefore, the sole purpose of this letter is to provide additional information that was not available to you through the chart notes that were sent to your office upon the instructions of Mr. Johnson. I have not been asked to do a complete narrative report, although I would be pleased to do so if requested by you. Instead, I am simply going to comment on the nature of treatment, the extent of treatment, and the cost of treatment.
 
I will start by noting that when Mr. Johnson came to me regarding the accident referred to above, I did a thorough examination, and as a result I was able to make the following diagnosis: (D.C.: insert here a brief summary of your diagnosis)
 
In my experience, and as confirmed by accepted chiropractic principles and practices, such a diagnosis requires an aggressive treatment plan to stabilize the patient and move him along to healing. Thus, I recommended that Mr. Johnson come for treatment four times per week for two weeks, thence three times a week for two weeks, followed by twice per week for 6 weeks, and one visit per week thereafter until he reached maximum medical improvement.
 
For the first part of a traumatically-injured patient's course of treatment, I am likely to treat all five CPT Code Regions, and then once he is stabilized, I can reduce the treatments to two or three regions per treatment.
 
I have not seen any correspondence from you to my patient, but I understand that you are objecting to the frequency of treatments and the average charge per visit. He did not state whether or not you mentioned a so-called "peer review" as the basis of your objection, but it makes no difference because my treatment plan and the charges are both well within generally accepted chiropractic practice in this state. I know of which I speak inasmuch as my office philosophy, treatment regimen, and charges are all based upon practices taught at continuing chiropractic education seminars.
 
I cannot comment upon your choices in this matter, but I will note that I have twice before gone up against so-called "peer review" doctors, and both times I was vindicated by the trier of fact. I am ready, willing, and able to assist my patient in accessing his full rights under his insurance policy, including working to provide additional information or testifying, if necessary. (Note to D.C.: go ahead with that tough talk even if you are not usually so aggressive. This adjuster is abusing your patient and you need to let her know that you are going to defend your practice and billings.)
 
Now, in my review of Robert's chart, I noted that all of the initial visits were billed with five-region CPT treatment codes, and that as he progressed, I treated fewer regions, until the average was three regions per treatment. Obviously the need to treat all five regions until he stabilized will increase the average cost per visit. My charge for a discreet treatment of any of the regions described by the CPT codes is just the same as allowed by the government.
 
But since half of my treatments involved all five, then four discreet CPT regions, I am entitled to billing with those CPT codes. Obviously, the increased charges will increase the average office treatment cost. However, the treatments to the additional areas was also justified by my notes.
 
In my review I also noted that on each of those occasions when I treated my patient in five discreet regions (resulting in five charges, of course), Mr. Johnson was still unstable and in pain just from daily living. Later, when I treated four CPT regions, you will note that my patient had presented with complaints of increased pain from the normal activities of his living, and on four occasions from work requirements that he had to perform in order to maintain his job.
 
I am sure one could find other doctors in the area who may not subscribe to the established practice of intensive care to stabilize a traumatically-injured patient. Thus, their overall treatment costs are bound to be less, and hence, less per treatment on average. But I subscribe to the generally accepted chiropractic principle that with a patient who is unstable from a traumatic injury, intensive chiropractic care is ESSENTIAL TO STABILIZE the patient. In fact the patients will stabilize sooner, and their treatments overall will be fewer with intensive care up front.
 
Of course it is not my job to figure out what rights my patient has for reasonable and necessary treatments under his insurance policy. All I can say is that in my professional opinion, Mr. Johnson required intensive treatments up front to stabilize his condition brought about by the accident referred to above, and that all care was medically necessary and charges therefor were reasonable.
 
Given this information I am confident you will have sufficient basis to reverse your decision and to pay Mr. Johnson's reasonable and necessary chiropractic care billings. I would be pleased to provide any additional information you may require.
 
Sincerely Yours,
 
 
 
(insert your name), D.C.
 
 
cc: Robert Johnson