Are Doctors of Chiropractic being “managed” straight to the poorhouse by America’s managed care industry?
By Randy Southerland
In a quaint brick office on Main Street in Kennesaw, Ga., Cris Welch, D.C., is seated in front of a computer screen where she connects to the new world of chiropractic managed care. It’s Tuesday and even though a steady stream of patients are coming through the door, this busy chiropractor won’t touch a single one.
Every Tuesday of every week she has to concentrate on filing insurance forms and patient treatment plans (PTP). While it’s not a job she particularly cares for—she would rather be adjusting patients as she does on other days—the process is vital so that the office can collect on benefits held by patients enrolled in HMO and PPO plans.
Instead, her father, Jim Eaton, D.C., will be on the floor providing care to the more than 350 patients that come in each week. The two decided that her time would be better spent dealing with insurance providers and the intermediary “clearing houses,” such as American Specialty Health Network and American Chiropractic Networks, that decide if and how often their policy holders should receive care. After all, if the documentation isn’t submitted correctly no later than a patient’s fifth visit, they won’t get paid.
It’s a time consuming process. Preparing a PTP can take up to 45 minutes and the rewards are sometimes meager. After getting a $25 co-pay and submitting the required documentation, the total claim is reduced to a mere $26.
“I’m submitting paperwork for $1,” says Welch. “By the time you submit the claim you’re in the hole.”
Today’s world of managed care is a far cry from chiropractic’s long history when there was little if any insurance coverage, and fees were a matter decided strictly between doctor and patient.
Joel Margolies, D.C., a 25-year veteran practitioner, recalls that up until the late 1970s few DCs worried about patients with insurance. In the wake of the Wilkes anti-trust suit against the American Medical Association (AMA) and growing acceptance by Medicare and patients in general, the number of plans that included chiropractic services grew from a trickle to a flood.
For many doctors the heady days of old-fashioned insurance reimbursement came to an end with the advent of managed care and its efforts to contain rising healthcare costs.
“So the insurance companies began to transfer some of that responsibility for (financial) risk back to the providers and also the patients,” says John Lockenour, a Bedford, Ind., D.C. who lectures on managed care issues for KATs Management.
In the early 1980s almost 90 percent of Lockenour’s revenue came from insurance payments, with patients providing little more than 10 percent, he recalls. Last year, however, more than half of all of his office revenues were coming directly out of patient’s pockets.
At the same time that insurance companies are attempting to reduce their outlays for chiropractic services, the number of companies paying for those services has increased.
A study from Mercer Consulting indicates that 80 percent of HMOs, 91 percent of PPOs/POS and indemnity plans and a full 95 percent of employers offer at least one plan including chiropractic care.
This acceptance of the profession has stemmed largely from demands by the patients who want access to chiropractic services.
“The idea behind managed care was to keep things within some degree of control so there was no abuse,” says Margolies.
That seemingly even-handed approach has since taken the form of fee cutting and micromanagement or even outright denial of care by distant and unseen regulators.
“They (insurance companies) will cut the amount of money they pay the doctor or the number of visits you’re allowed or the fees they’ll cover,” he explains. “It all depends on the person who reads the review. Since they’re paper reviews, they don’t really see the patient.”
In fact, many doctors say that the way managed care organizations dole out approval for patient services is all about money and has little to do with what is needed to get them well. Few HMO plans such as Blue Cross/Blue Shield, Cigna, Aetna and United Healthcare will pay for more than 20 visits, and even getting that number can be difficult.
“We typically ask for 15 to 20 visits and we typically get about 10 to 13 approved,” says Eaton, whose practice includes many local teachers, state employees and public safety workers. “That means that after the 13th visit we have to resubmit a TPT.”
Once those 20 visits are done there are seldom payments for any more. Then the doctor is faced with the prospect of converting patients to cash or saying goodbye.
“That does not—in my office—mean they’ve run out of care,” says Eaton.
He contends that through education and keeping patients updated on what their insurance does and doesn’t cover, many eventually switch to an optimum care cash plan that “usually ends up being pretty close to what their co-pays have been in the past.”
While some patients recognize the value of care and are willing to pay out of pocket for it, many doctors admit that it can be tough to sell. In fact, the kind of patient attracted by managed care may not be the one best suited for a doctor’s practice.
“We thought we’d get these referrals because we’re in the book, but the people came in because of the $10 co-pay,” says Dawn Falite, D.C., who practices in Alpharetta, Ga., and has since gotten out of managed care networks. “They weren’t interested in long-term care and they weren’t the same type of patient we were looking for and we’ve built our practice on.”
The disconnect between doctor and patient can become particularly acute when patients don’t really understand their polices or the ways in which providers interpret provisions.
“It’s very unclear as to when the person really finishes their managed care schedule,” says Margolies. “They have 30, 40 or 50 visits specified in their book, but it’s given out in drips and drabs through treatment plans.”
A particular condition may be approved for the usual 20 visits and then the company will approve no more until another condition arises—whether the DC thinks they need more or not.
In addition, some companies may pay DCs less than other health care professionals for performing the same services. That trend prompted the American Chiropractic Association (ACA) to sue Trigon Blue Cross Blue Shield of Virginia for discriminatory reimbursement practices against chiropractors. Among other things, the ACA’s complaint includes allegations of antitrust violations and of Trigon unfairly paying doctors of chiropractic 40 percent of what it pays medical doctors for the same services.
“They have actually said to us that they think our education is not as comprehensive as the medical doctors so therefore they’re going to pay us less for the same exam codes,” says John Gentile, D.C., a Miami practitioner who chairs the ACA’s Insurance and Managed Care Committee.
The ACA has also sought to work with insurance carriers and chiropractic networks to allow for more patients visits. The number of visits is frequently a bone of contention for every doctor. Where, after all, do the companies arrive at these numbers?
Gentile says the ACA has found that some companies have suggested the limits are based on in-house experts or research literature. “They’re very vague on where they get (visit limits) from,” he adds.
“I think it’s a random number that they pulled out of a hat because there’s not been any research to show that would be the normal number of visits to resolve the patient’s problem or each maximum improvement,” says Lockenour.
Margolies suggests that the 20-visit range is usually based on Mercy document guidelines for particular codes and is just enough to give patients symptomatic relief for their condition.
In addition to limiting visits, companies have also found creative ways to reduce reimbursements. Fees are almost always discounted from the doctor’s usual schedule, and the amount of paper work required to get that discounted fee can be considerable.
“Ten years ago we were writing off maybe 5 to 6 percent,” says Lockenour. “Last year we wrote off 16 percent. In the next 5 to 10 years the average office will have to write off at least 20 percent.”
Some plans ask for even higher write offs—sometimes as much as 75 percent for the initial visit and 50 percent for each one thereafter. Other companies will only pay a “global” or fixed fee that covers every service a doctor chooses to provide during a particular visit.
“Everybody who walks in my door could have a little bit different tweak on their insurance or third party reimbursement,” says Lockenour. “So that creates more paperwork for my staff for us to keep up and know what that coverage is and help the patient understand their own coverage.”
In perhaps the unkindest cut off all, many doctors often find they must pay for the privilege of having their fees reduced and practice judgment questioned, says Mark Kimes, D.C.
“The first time you get in you may pay a credentialing fee that can range from $250 to $1000,” says the Salinas, Calif.-based practitioner. “Doctors are paying to have their fees cut and their visits limited.”
This initial fee to get into the network is often followed every year or so by a re-credentialing fee.
Kimes, who also consults with doctors on practice management, says that because of high co-pays and low reimbursements, many chiropractors will find it more profitable to convert managed care patients to a cash basis.
To meet patient demand for chiropractic and other alternative services, many companies have begun offering affinity programs that allow access to alternative providers at a discounted rate. These programs shift the cost of care even further onto the patient and doctor since the insurance carrier typically pays nothing to provide the service. All the cost is borne by the patient who pays the discounted fee and the