Chiropractor Chart Note Letter to Adjuster Denying Chiropractic Insurance Benefit Billings: Treatment PALLIATIVE, NOT CURATIVE

 
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.
 
I have not seen any correspondence from you to my patient, but I understand that you are objecting to chiropractic treatments because they do not "cure" the patient, but only make life temporarily better. Robert did state that you mentioned a so-called "peer review" as the basis of your objection; he also states that he asked for a copy of the review, and I will be eager to read it as well.
 
It will not affect this course of treatment, however, 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.
 
As for the review of my chart notes, please let me know if there are any abbreviations or notes that you need for me to explain. I mention this inasmuch as my treatment and office notes clearly show the incoming examination, complaints of pain, and restrictions on what Mr. Johnson could not do because of his injuries. As treatment progresses, you will kindly take note that my patient reported he was able to work longer without pain and that his day-to-day life improved to the point that he could resume doing many of his chores and activities without debilitating pain.
 
I have no idea where you came up with the standard of denying care that is "palliative, not curative" because that is not something I have seen in automobile personal injury claim practice but once before, and it was debunked then, as it should be this time. I will admit to running across that standard in the past in worker's compensation claims, but that is a system with wholly different administrative rules, and further, I do not think that standard is actively in play there, either.
 
I have been called to testify in insurance litigation, and I was told there is no restriction on jury instructions allowing them to discount medical treatments that are just helpful to the injured patient in leading a normal life, as opposed to curing the underlying disease. Probably one reason your standard has been soundly rejected is that so much of our modern medicine does just that: it helps people, even though it does not cure them. As noted in The Journal of The American Medical Association, Volume 269 (5), Issue February 3, 1993:
 
"The expensive, technologically advanced treatment for coronary artery disease, such as coronary angioplasty, bypass surgery, thrombolytic therapy, antiarrhythmic drugs, and pacemakers, are all palliative, not curative; none do anything about the underlying arteriosclerotic disease that causes the problem. JAMA, 269(5), Feb. 3, 1993."
 
 
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 he has made the steady progress mentioned above. What you do not have before you is my narrative statement that (as first stated in his diagnosis), all of Mr. Johnson's treatments and charges therefor are the direct result of the trauma of this accident and all are reasonably and necessarily incurred, as confirmed by generally accepted chiropractic standards.
 
Furthermore, as my patient told you, Robert will need continued care to maintain the plateau he has currently achieved. Over time we do hope to make further improvements in his condition, but I cannot predict how much of the severe soft tissue damage he suffered can be reversed.
 
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 continued care to date and in the future 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