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 diagnosis, nature of treatment, the extent of treatment, and the results 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 can be made entirely based upon subjective complaints. It is true that in the case of severe soft tissue injury, we will often find spasms, especially upon palpitation. But the absence of objective evidence does not rule out pain.
 
It is a proven truth that the existence of pain-even severe pain-does not have to result in any objective findings. Please consider standard medical practice for proof of that axiom. For example, the fact is that a good clinician uses her skill and experience to assess the truthfulness of the patient, and marries her clinical observations and background into a coherent assessment to form her diagnosis.
 
Since our medical care depends so heavily on the subjective as part of nearly all clinical work, even when there is no objective test or measurement of pain, it seems reasonable to require that adjusters should give credence to the conclusions of an experienced doctor, even if they are based solely upon subjective information. An example of this is the diagnosis of fibromyalgia, which does not manifest in any objective manner, but is diagnosed by subjective complaints exclusively.
 
I performed examinations at the start of my treatments. The course of treatment is well-documented. Subjective complaints are a valuable tool of doctors in making a clinical diagnosis. In fact, "subjective" is the first step of SOAP, the acronym for a plan for diagnosis and treatment of medical conditions (Subjective, Objective, Assessment, and Plan).
 
I have been at this business a good many years now, and thus I am adept at reading people and my diagnosis is in large part based upon that skill. As you can see from my notes, I am through in my examination and my assessment is based upon the evidence before me, including the demeanor of the patient. Based upon my diagnosis, I concluded that an aggressive treatment plan was required 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.
 
Against this array of experience and medical tradition, you propose to look to an anonymous "peer review" for the best recommendations. 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 him know that you are going to defend your practice and billings.)
 
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 I made a thorough clinical diagnosis, and in my professional opinion, Mr. Johnson suffered the injuries recited in my diagnosis and 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.
 
Very Truly Yours,
 
 
 
(insert your name), D.C.
 
 
cc: Robert Johnson