How often has this happened in your practice? You submit an insurance claim, only to receive a
denial, labeling the treatment or diagnostic testing you conducted as "observational" or
"investigational." It's a response familiar to many doctors of chiropractic.
"This is happening so frequently now," says Charles Herring, DC, president of the Foundation for
Chiropractic Education and Research (FCER). "Someone representing the insurance company does a
literature search and writes up a policy position stating that X is not a covered benefit,
because it's been determined from the literature [to be] an observational or investigational
service." These documents, usually called "clinical policy bulletins," mean that even before
your claim can be considered, you have to come up with scientific literature to effectively
counter the insurance company's ruling.
That's why it's more important than ever for today's doctor of chiropractic to keep up with the
scientific literature. "Evidence-based health care is the paradigm now. But it's also being
abused by third-party payers, who don't always appropriately apply evidence in the patient's
best interest," says Bill Meeker, DC, president of Palmer College of Chiropractic West in San
Jose, Calif. "An insurance company may misquote evidence, take it out of context, or apply it
unfairly across providers, patients or plans."
"In Ohio in particular, we are constantly teaching our doctors how to counter the arguments of
[insurance companies] consultants, who are using outdated thinking and research, and
misapplying them to clinical practice," says Ronald Farabaugh, DC. Dr. Farabaugh is the founder
of the Medical Referral System, a program that helps DCs generate referrals from other
healthcare specialists, and he practices in Columbus, Ohio.
"For example, I hear all the time from consultants who deny care because of concerns about
physician dependency. But if you look at the literature, when it comes to chiropractic
manipulation, there is none," he says.
"Another issue is the insistence that soft-tissue injuries should have healed after six to eight
weeks. But dozens of papers show that many times soft-tissue injuries progress to a chronic pain
state. If you know the literature, you can send it right back to [the insurer]," says Dr.
Fortunately, it's easier than ever before to make the evidence work for you-not against you.
Searches that once required day-long trips to a medical library can now be conducted online with
just a few mouse clicks. Indeed, says Dr. Meeker, keeping abreast of current research is a
professional responsibility for the con-temporary doctor of chiropractic. "Start keeping up with
what's going on. It hasn't been acculturated in the profession until recently, but you have to
stay abreast of the literature. That's what's driving decisions, and if you are well armed,
you'll do better than those who aren't."
“Evidence-based chiropractic makes sense from an economic standpoint, a referral standpoint and a case management standpoint. It's all about trying to secure a better outcome for your patient, and I don't know how you do that if you're not up on the literature.”
~ Ronald Farabaugh, D.C.
Defense Against Denials
Mark Dehen, DC, chair of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP),
recently encountered just such a situation in his North Mankato, Minn., practice with a
patient who was experiencing the neck, low-back pain and headaches typical after an auto
"After the usual course of care, the patient was doing well but still had some complaints," says
Dr. Dehen. "Her care was eventually denied by the insurance company, and we went to mediation,
in which an independent medical examiner decided that all her symptoms were the result of
previously existing fibromyalgia, rather than the accident."
The patient had never been diagnosed with fibromyalgia, and Dr. Dehen conducted a literature
search. He found several articles indicating that motor vehicle trauma actually appears
capable of triggering fibromyalgia-not through direct biomechanical injury- but as a stressor
that can, in concert with other factors, result in the development of chronic widespread pain.
"In my report to the patient's attorney, I explained that the fibromyalgia may be a legitimate
diagnosis, but either it was a result of the collision, or the collision exacerbated previously
undiagnosed fibromyalgia," he says. "The attorney won the case, I got paid, and the patient got
coverage and wasn't saddled with the bill from my office. It took me about 20 minutes on PubMed
to pull up the articles that won the case."
In his role with CCGPP, Dr. Dehen is particularly knowledgeable of and current with the
scientific literature. But even if you're not, in many cases, the work of searching and
synthesizing the literature has already been done for you-you just need to know where to look.
The Latest Reviews
Organizations like CCGPP and FCER make it their business to stay on top of the latest research
affecting chiropractic, and they frequently publish the types of reviews and syntheses that you
need to make your case to third-party payers. Two recent examples, which should be on the
shelves in all chiropractic offices, are:
The findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain, released in 2008
in a special supplement to the journal Spine 2008 (Feb 15); 33 4S :S3. The monograph resulted
from six years of review of published neck pain research, including almost 32,000 research
citations and more than 1,000 relevant studies.
The November 2008 and January 2009 issues of the Journal of Manipulative and Physiological
Therapeutics (JMPT), which contain the results of literature syntheses conducted by CCGPP on
low-back pain and related leg complaints, chiropractic management of myofascial trigger points
and myofascial pain syndrome, chiropractic management of tendinopathy, and manipulative therapy
for lower-extremity conditions. (The February 2009 issue also contains a special supplement
reprinting the Neck Pain Task Force's findings.)
"This is very exciting research," says Dr. Meeker. "For example, it's been somewhat accepted
that chiropractic adjustments are only good for acute back pain, but not for chronic back pain.
But the monograph published in Spine finds that there is just as much randomized controlled
evidence for the effectiveness of adjustments in chronic back pain."
Reversing Insurance Policies
These major literature syntheses have also led to the over-turning of entire insurance company
policies-not just changes for individual doctors. In September 2007, the insurance giant
United Healthcare (UHC) issued a policy denying chiropractic coverage for pediatric cases and
headaches. CCGPP gathered its literature syntheses, conducted additional searches and pulled
together commentary from experts in the field for a letter to UHC, signed by key stakeholder
organizations, including the ACA.
"A month later, we received our response: United was suspending both of those policies," says
Dr. Dehen. "In February 2008, the company retracted the pediatric policy altogether and reworked
the headache policy to allow chiropractic coverage."
Similarly, a CCGPP synthesis helped to address a workers' compensation crisis in California,
which was severely limiting chiropractic care for injured workers through the aggressive
application of utilization reviews. "Using a synthesis, we demonstrated that chiropractic
manipulation is appropriate for all phases of low-back pain, and used expert opinion to bolster
[the points] where the evidence was weak," says Dr. Dehen. ''As a result, California's
Occupational Disability guidelines have been modified, effectively raising the amount of
chiropractic coverage allowed-with proper documentation-from 12 to 24 visits a year."
Keeping Up with the Literature
This spring, CCGPP plans to issue its neck report endorsing the Bone and Joint Decade 2000-2010
Task Force on Neck Pain, as well as an original thoracic literature synthesis. (Visit www.
ccgpp.org for links to all published documents and outstanding reports.)
Using the CCGPP guidelines published in JMPT, Dr. Farabaugh was able to show a local doctor of
chiropractic how to increase his clinical income by $58,000 annually. "This is just by using
good quality case management recommended in that pa-per-such as [conducting] proper exams at the
proper times and recommending proper exercises at the proper times," he says.
Doctors of chiropractic can also keep up with the literature by attending meetings such as the
ACC- RAC; FCER's Research Congress; the North American Spine Society annual meeting, which brings together specialists ranging from neurosurgeons and radiologists to physiatrists, doctors of chiropractic and pain management specialists; and the Integrative Healthcare Symposium-an extensive expo on integrative and complementary medicine. Dr. Meeker also recommends subscribing to JMPT, Spine, the Spine Journal and Manual Medicine.
Another indispensable research tool is DCConsult, an online search service provided by FCER,
which incorporates PubMed and Google Scholar search engines. Beginning in early 2009, FCER made
DCConsult open access. (Special FCER products and benefits, such as teleconferences and journal
clubs, are still available only to FCER members.)
"DCConsult will help doctors of chiropractic quickly locate the most-current abstracts and
information. Search results of-ten include articles the same day they are published-and the
literature searches are easy and, most important, accurate," says Dr. Herring. "More search
capabilities are added weekly and include Merck Manual and other diagnostic tools. Soon doctors
will be able to access tutorials, educational programs, nutritional approaches, and information on techniques and more," he adds.
"Evidence-based chiropractic makes sense from an economic standpoint, a referral standpoint and
a case management standpoint," says Dr. Farabaugh. "It's all about trying to secure a better
outcome for your patient, and I don't know how you do that if you're not up on the literature."