MCO Denials and Performance Improvement Agreements

The ICS has recently received a number of complaints from members regarding the handling of chiropractic claims by certain managed care organizations with which the doctors have provider agreements. The complaints fall into several categories: chiropractic benefits are advertised to employers and employees, but are not truly available because reviewers routinely deny care based on "lack of medical necessity" (in contradiction to the doctor’s judgment); "medical necessity" is determined by peer comparison and when care delivery in a particular case does not fit into statistical standards, coverage is denied; insurers have denied coverage based on what they cite as "evidence-based guidelines" that supposedly show how chiropractic was not effective for the type and duration of certain treatments (i.e., it has been reported that some companies will not pay for rehabilitative care, only for pain relief); and insurers frequently deny claims for adjustments and therapies performed in the same visit, sometimes unilaterally changing coding and paying at lower rates.

Increasingly, insurers are compiling their own databases of claim information, using statistical analyses to dictate care and deny claims. In some cases, patients with stubborn conditions in need of treatment may be denied coverage for the full range of recommended care because that care is beyond a statistical norm for the patient’s condition. Participating providers are also being forced to choose between signing "Performance Improvement Agreements" that require the doctor to bring his or her claims within statistical norms or terminate participation in the network.