REPRINTED WITH THE KIND PERMISSION OF THE
CALIFORNIA CHIROPRACTIC ASSOCIATION JOURNAL
Fighting Back on Mercy Document Abuse
Gary N. Lewkovich, DC, FAFICC and Michael Blott, DC, FAFICC
Increasingly, it seems many chiropractic "reviewers" misuse and/or misquote various guidelines when recommending cuts in personal injury reimbursements. The Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Document) is one study especially prone to such abuse. This document, first published in 1992, represented a consensus of 35 highly respected doctors of chiropractic. It required three years to fully develop. Hugh volumes of literature were reviewed in the process. The principal sponsoring agencies included the Congress of Chiropractic State Associations, the American Chiropractic Association, the Canadian Chiropractic Association, the International Chiropractors Association, the Association of Chiropractic Colleges, the Federation of Chiropractic Licensing Boards, and the Foundation for Chiropractic Education and Research. With such credentials, it is no surprise that the opinions expressed in the Mercy Guidelines carry considerable weight in the healthcare arena.
The publication of the Mercy Document represented a tremendous advance for chiropractic. Among many things, the appropriateness of many forms of evaluation, exam, and treatment for various injuries and conditions were rated. For the first time, there was a widely respected source with evidence to support what chiropractic care does and does not do. Overall, the document was highly positive for the profession.
However, like any document, especially one over 220 pages long, selective quoting or misquoting of the information contained therein can dramatically alter the actual message. Enter the insurance company's reviewer. Armed with a few, carefully chosen phrases, extracted without regard for the condition in question or the myriad of disclaimers, he or she proceeds to attack another chiropractor's treatment. The goal, of course, is to discredit, embarrass, or intimidate this doctor of chiropractic, thereby making it easier to reduce or deny reimbursement.
No where is this practice more prevalent than in personal injury whiplash cases. Here, the reviewers seem especially motivated to excerpting the Mercy Document and extrapolating far beyond the intent or letter of the study. One of the most common statements that we have found involves a reviewer's opinion that goes something like the following: "The Mercy Document only allow for six to eight weeks of care in uncomplicated case. Complicated cases may require three months of care. Therefore, any treatment beyond the three month time limit should not be reimbursed."
As doctors of chiropractic, we are most concerned with getting our patients well. We don't take or make the time to study the vast amount of literature that pours forth in our specialty. Our collective ignorance on the content of this study makes us especially prone to being duped by quotations like the one above. Don't let this happen to you. Most treating doctors have not read the Mercy Document. In fact, many doctors have never even seen the document. Insurance company reviewers know this and take great advantage of our ignorance on this important topic. It is time to fight back. First, read the Mercy Document (and any other guideline that is quoted at you). Then send a cover letter that parallels the following one. Attach to it the accompanying Fact Sheet, highlighting those items appropriate to your particular case.
Dear (insert name of insurance company representative):
I have read the opinion of your "expert," (insert name of expert) as quoted in your letter dated (insert date). He/She stated, apparently with complete confidence, that treatment for whiplash should not exceed three months, even in complicated cases. His only support listed for this opinion was the Mercy Document. Presumably, he/she is referring to the "Guidelines for Chiropractic Quality Assurance and Practice Parameters."
In researching this position, I discovered certain facts in conflict with your expert's point of view. The enclosed Fact Sheet outlines the realities of the Mercy Document and the treatment for whiplash. As you will discover, your expert was mistaken. Additional support for treatment beyond three months is also provided in the enclosed Fact Sheet.
Please provide your expert a copy of the Fact Sheet so that he/she may address this topic in a more informed manner in the future. If such misquotations of the "Mercy Document" appear from your expert in the future, I must assume that you have willfully withheld this information or that your expert has chosen to ignore the facts of the matter. In either case, it should make for an interesting discussion before the arbitrator and/or judge.
Now that the errors have been rectified, there is the issue of payment for my medical bills in this case. As you are aware, your insured's insurance policy provides for payment of reasonable and necessary medical expenses. Since my charges are both reasonable and necessary, I expect payment without any further delay. Thank you in advance for your anticipated cooperation.
cc: (Patient's attorney)
Regarding the "Guidelines for Chiropractic Quality Assurance and Practice Parameters" (MERCY DOCUMENT) and Whiplash Injuries.
1. The Mercy Document addresses soft tissue injuries in general, with the majority of the literature coming from low back studies.1 There is no reference that these guidelines also apply to CADS (Cervical Acceleration/Deceleration Syndrome), commonly known as whiplash injuries. In fact, there is considerable evidence that CADS injuries are a quite distinct form of soft tissue injury.2 Complicated CADS cases can require PRN care beyond 12 months.3
2. The Mercy Document contains a general disclaimer that must not be overlooked. It reads as follows: "These guidelines, which may need to be modified, are intended to be flexible. They are not standards of care. The Commission understands that alternative practices are possible and may be preferable under certain clinical conditions. The ultimate judgment regarding the propriety of any specific procedure must be made by the practitioner in light of the individual circumstance presented by each patient".4
3. The disclaimer further states that "This document may provide some assistance to third-party payers in the evaluation of care, but it is not itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity." 5
4. The Mercy Document further states in Chapter 8, titled "Frequency and Duration of Care," that they are "NOT designed as a prescriptive or cookbook procedure for determining the absolute frequency and duration of treatment/care for any specific case."6
5. The Mercy Document states that treatment can continue to be warranted provided it can be shown to "provide sufficient care to restore health, maintain it, and prevent the recurrence of injury or illness."7
6. State mandated Worker's Compensation guidelines and conservative managed care companies allow for continuing care beyond three months when there are residuals requiring more than home therapy can offer.8
7. It is entirely reasonable to provide treatment beyond three months for CADS injuries when any of the following factors are present:
a) significant complications.9
b) flare-ups that are not amenable to home therapy alone.
c) supportive care required to maintain Activities of Daily Living or to prevent deterioration of the patient's condition.
d) permanent residuals not addressable by more conservative means.
e) certain risk factors.
8. Failure of a doctor of chiropractic to provide needed care based solely upon a "cookbook" cut-off of three months of care for any injury could be grounds for patient abandonment, even in a managed care setting.14
1. Mercy Document, Page 117
2. Arthur C. Croft, DC, MS, FACO, Of Guidelines and Gridlines, Dynamic Chiropractic, April 20, 1998.
3. Croft AC. Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). American Chiropractic Association Journal of Chiropractic 30 (1):41-45, 1993.
4. Mercy Document, Page IV
5. Mercy Document, Page IV
6. Mercy Document, Page 117
7. Mercy Document, Page 117
8. California Labor Code 4600, Landmark Healthcare guidelines, and American Specialty Health Plan guidelines for chronic/recurrent conditions.
9. Nordhoff LS, Jr., DC, Motor Vehicle Collision Injuries: 201, 1996.
10. Physician's Guide: Medical Practice in the California Workers' Compensation System, Department of Industrial Relations, second edition: 37, 1997.
11. California Labor Code 4600.
12. Physician's Guide: Medical Practice in the California Workers' Compensation System, Department of Industrial Relations, second edition: 37-38, 1997.
13. Croft AC. Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). American Chiropractic Association Journal of Chiropractic 30 (1):41-45, 1993.
14. In Wickline v. State of California (1986)