State Farm v. 664987

In State Farm v 00331 filed in 2020, State Farm claimed that a clinic was licensed with AHCA but it had a medical director that was “appointed in name only.”

For instance, State Farm claimed  that RCAs and CCPAs were not qualified to perform active therapies on patients, specifically therapeutic exercise and manual therapy.  State Farm cited the AMA CPT Manual’s Fourth Edition which states that these are skilled therapeutic procedures which must be performed by “a physician or other qualified healthcare professional”

The CPT Manual defines “a physician or other qualified healthcare professional” as “an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional services.”

The CPT Manual defines “clinical staff” as “a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service, but does not individually report that professional service.”

State Farm says that RCAs and CCPAs are “clinical staff” and not a “physician or other qualified healthcare professional.”  If this is correct, then the therapeutic exercises and manual therapy are non-reimbursable because they wouldn’t be properly licensed to have performed the services.

The Medical Director testified that he would only visit the clinic one day per week and all of his time was devoted to examining patients.  He stated that he saw 25 to 30 patients when he would visit performing examinations where he would declare that patients had

EMC’s, and would spend “five to ten minutes per month” reviewing ten bills that were pre-selected by the clinic.  He only reviewed the bills and not the notes or other paperwork.  The Medical Director also testified that he “doesn’t get involved with payments” and doesn’t know if the deductibles and co-pays are being collected.  He stated that he “didn’t know” of any policies regarding the collection of copays and deductibles.

The deductible was designed to “create a negative incentive for insureds to control their consumption of medical services.  That is, if insureds are required to pay a deductible every time they visit a medical clinic, they will be less likely to make unnecessary visits to the medical clinic.”

Patient DJ stated there was never a discussion about a 20% copay with anyone at the clinic.  Patient ADVP stated they never received a bill from the clinic and that, even though their injury lawyer dropped their case, they would “never receive a bill from the clinic.”  Patient KF stated the clinic never told me about the cost of treatment, a co-pay, or payment arrangements and “not to worry because your auto insurance takes care of everything.”

EMCs: The Medical Director was also performing examinations on the patients.  He would provide an EMC on “the vast majority of patients.”  He testified that every patient he examined had an EMC unless they reported no pain.  The Medical Director performed an exam on a patient four days post-MVA who reported “1-2” level pain on a scale of 10 and was given an EMC by the Medical Director.  Most of the patients only had subjective reports of pain when they were given the EMC and did not have any x-rays or MRIs at the time of the EMC determination.

MRIs: The patients were ordered for MRIs by a chiropractor working at the clinic but the results were not used for any purpose documented in the medical records.  The MRIs were ordered on the first visit even if they didn’t report any radiating pain, numbness or tingling, or weakness in strength.  The chiropractor documented that he “reviewed the MRI findings with the patient” but didn’t modify the treatment plan based on the MRI findings.

Treatment: Almost every patient received the same six services from the clinic which included five passive modalities (hot/cold packs, electrical stimulation, manual therapy, chiropractic manipulations, and ultrasound) and one active therapy (therapeutic exercise).

Therapeutic Exercise:  The AMA Guidelines states: code 97110 (therapeutic exercises) requires the practiciioner to maintain direct contact (ie visual, verbal, and/or manual contact) during the service, so 97110 should only be reported when the practitioner is providing therapy to one patient alone.  In this case, patients stated in EUOs that a staff member sits in the middle of the room and “monitors” everyone.  The patients stated in multiple EUOs that there are usually three or more people in the room doing exercises.

Ultrasound: The clinic was using an ultrasound device that affixes to the patient’s body.  Ultrasound requires constant attendance and “direct (one-on-one) patient contact.”

Manual Therapy:  The clinic was having RCAs and CCPAs to perform manual therapy.  State Farm claims that RCAs and CCPAs are “clinical staff” and couldn’t perform those codes.  I disagree on that issue.

Impairment Ratings:  Despite all of the treatment, virtually every patient received a final report that showed a permanent impairment which means that (1) the treatment was unnecessary because not a single patient got better or (2) the permanent impairment ratings were false and exaggerated.