Geico v. 2206

In Geico v 22206 filed in 2019, Geico claimed that a pre-determined treatment protocol was taking place.  Geico claimed that:

-An impossible number of patients had listed on their examination report that the “Soto Hall” test was positive for “a fracture at C7 and/or T1”.

-The initial exams were all billed as a 99203 even though some patients required a level 1 or a level 5.  Geico made a big deal about every patient getting billed for a 99203 which is honestly BS.  This is very commonly billed.  Everyone knows billing a level 4 or 5 for every patient is a red flag but complaining that every patient is billing a level 3 is a stretch.

-The provider billed 77003 (fluoroscopic guidance) even though that is included whenever a provider performs pain management injections.  In the old days, when I used to trek to school in the snow with no shoes 10 miles just to get to school, you used to be able to bill separately for 77003 but that changed in January 2011 when Medicare decided it was included in the injection procedure.

-The provider was billing for pain management injections within the first three months (sometimes the first week) of treatment and before the patient failed conservative treatment.  Generally speaking, for a couple patients here and there this would be normal, but when most patients receive this care it would be a pre-determined treatment protocol.

-The provider performed EMC’s “in-house” with their PA’s and that virtually every patient received an EMC including minor children and patients who presented with low levels of pain.  Clinics need to beware of doing EMC’s “in-house” because an insurance carrier can easily say there is a bias to get the additional $7,500 in coverage.  Providers who make the EMC determination also need to make sure they don’t “give” an EMC for red-flag patients like minor children, patients reporting low pain, patients who are insured by aggressive insurance companies that sue medical providers.

-The provider billed for 7 CPT codes per visit including chiropractic adjustments/physical therapy, and hot/cold packs.  This is a major red flag for a carrier wanting to allege over treatment.  One or two patients getting 7 CPT codes here and there is not a problem…but the problem arises when there is a pattern of most patients getting 7 CPT codes per visit.  Most providers are billing 5 CPT codes.  There is nothing illegal or unethical about billing 7 CPT codes, however, this is a red flag for a carrier looking to sue a medical provider.

-One chiropractor at a specific location treated 16 Geico patients in one day which added up to about 28 hours/1680 minutes in a single day.  Geico alleged that it was impossible for one chiropractor to perform 27 hours of work and/or supervise the treatment.  It is important to note that Geico’s math was blatantly wrong because they did not factor in the “8 minute rule” for time based codes.  Geico is only one insurance company so that means when you add in the State Farm, Progressive, Allstate, etc insurance companies that there are probably over 100 hours of time in a single day and being “supervised” and “performed” by a single chiropractor on any given day.

Geico claimed a violation of Chiropractic Advertising Laws based on their website.  For instance, the website stated that: (1) the chiropractor owned a referral company under his same last name and that the referral company violated chiropractic advertising laws by failing to mention the name of the chiropractor who owned the company and by failing to list the names of the treating physicians; (2) “insurance companies can deny weak claims… they can go to great lengths to find ways not to pay weak claims… you need someone on your side to help you strengthen your claim quickly… the sooner you call the more we can help… we work with you to effectively assess and address your injuries, which helps strengthen your claim…call from the ambulance, ER, or scene… we are your advocate…we provide documentation on what improves your claim and know what doesn’t improve your claim…we can help move your case full speed ahead…

Geico claimed that the chiropractic clinics weren’t properly supervised even though they were owned by a licensed chiropractor.  Remember, Florida Statute 400.9905 still requires the “physician owner” to properly supervise the location.  Geico also claimed that the owner was a chiropractor and, therefore, never qualified as an exempted clinic because they performed services (prescribing drugs, pain management injections and surgery) which were outside the scope of chiropractic.  In other words, if the chiropractor cannot prescribe drugs, perform injections, or perform surgery how could he/she legally supervise the medical doctors performing the work and ensure patient safety which is the intent behind AHCA licensure.