Common Predetermined Treatment Protocols
Here are some examples of a Predetermined Treatment Protocol
This is also known as “cookie cutter treatment” and insurance companies sue doctors over this. Many medical providers are doing it without realizing, especially practices that use young associates to do most of the treatment.
First, how does State Farm define a Predetermined Treatment Protocol:
Based upon a legitimate examination and diagnosis, a licensed professional must engage in medical decision-making to design a legitimate treatment plan that is tailored to the unique circumstances and needs of each patient based on several factors such as the severity of the injury, medical history, age of the patient, mechanism of injury, physical condition of the patient, and other factors. During the course of treatment, licensed professionals should modify treatment plans based upon the unique progress, or lack thereof, of the individual patients.
Treatment plans should be periodically reassessed and modified based upon the progress of the patient, or lack thereof.
Common examples of a predetermined treatment plan:
- Every patient getting prescribed “3 times a week for four weeks” during their initial exam. This is a common pattern. The insurance company would argue that some people reporting a low level pain (ie 1 out of 10) would require less visits while someone with a higher level pain (ie 10 out of 10) would require more than 3 visits per week.
- Every patient gets 30 visits. This could be 27 visits or 34 visits. The number in this post is irrellevant. Go to your ledgers and add up the number of your visits for the last 20 patients. The pattern is what matters. Again, someone who is really banged up after an accident might need an additional 20 visits from the “norm” vs a patient who is reporting 3 pain who might need 6 less visits.
Important example, let’s say you have two patients who have undergone 27 visits at your office. They both have extreme 10 out of 10 pain, are identical age, and have identical MRI findings. The only difference is one patient has $1,000,000 in BI coverage and the other has $10,000 in BI coverage. The client with the $1,000,000 in BI coverage can continue to treat for an additional 20 visits because there is plenty of insurance money to treat. Unfortunately, the patient with the $10,000 in BI coverage cannot afford to treat unless they offer to pay out of pocket. This mindset will help reduce the likelihood that you are treating every patient the same X number of visits.
Every patient getting the same two MRIs. Common sense tells us that out of twenty car accident patients most people will hurt their neck and low back but not every patient. Insurance companies are looking for doctors who always refer patients for the same MRIs over and over. For example, if a patient doesn’t complaint about low back pain then don’t refer for a lumbar MRI. If a patient has neck, low back, and right knee pain then refer for three MRIs. I have one doctor who always refers the patient for one an MRI of one body part. Oddly enough, it isn’t even the bodypart that hurts the most. Insurance companies are looking for a pattern. The only pattern should be “patients get MRIs of the body parts that cause them moderate to severe pain after treating for a couple of weeks and not getting better”
Every patient getting sent for MRIs on the first visit with the chiropractor. Insurance companies love targeting doctors for referring MRIs on the first visit. First, they argue that X-rays are the appropriate approach, especially because X-rays look for broken bones and MRIs are not the best tool for that. I have personally had an x-ray and 3T MRI of my left shoulder after falling and the x-ray showed the fracture…the 3T MRI showed the torn ligaments but not the fracture. Chiropractors should not be adjusting patients manually without first confirming there are no broken vertebrae. Insurance companies cite to documentation that 30-60 days post accident is appropriate if there is still pain after four week of conservative therapy. I’m not saying we should let State Farm/Geico/etc dictate medical care. If a patient has neurological issues, radicular complaints, a limp when they walk, then an MRI is very likely justified before the 30 days.
Every patient gets billed a level 4 exam (or level 5) exam. I can tell you right now the biggest reason insurance companies go after doctors is for upcoding the exams. First, I love you guys but your initial exams are not as detailed as you think to justify the level 4 or 5. State Farm and Geico have said in many lawsuits against doctors that billing a level 4 or 5 code for every patient is upcoding and unjustified given the fact that some patients report low pain and/or low property damage. Remember, the level of exam code billed depends more so on the complexity of the patient’s injuries and treatment.
Every report says the same “canned” statement like “patient enters the office in obvious distress” or “patient seen by ambulance” or “patient suffers from insomnia after the collision.” It is less likely that every patient has XYZ and more likely that you are using macros or a form document incorrectly. Unless you are a doctor who specializes in insomnia it is unlikely that virtually every patient you see has insomnia. These are all real examples I have seen in doctor’s notes.
Every patient has MRIs but there is no note in the file that “the findings of the MRI were reviewed and discussed with the patient.” This is just sloppy note taking on behalf of the doctor.
I want to end this on a simple idea. You may be a great doctor but not the best at documenting the treatment/exam. That’s ok. I get it. You went to school to be a doctor… not a note taker. But there are billing and coding experts like www.TargetCoding.com where they can help improve your notetaking. If an insurance company is already causing you problems or not paying your bills, contact me immediately.
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