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Dynamic Chiropractic
March 9, 1998, Volume 16, Issue 06

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Establishing "As Needed", "PRN" and "Supportive" Care

by Steve Freeman, DC

One of the most difficult areas in chiropractic management is recognizing the need for supportive care. Many of us who treat complex soft tissue injuries, including persistent subluxation complexes, understand that these patients may require periodic, ongoing chiropractic treatment.

However, with the current insurance climate masquerading under the guise of "quality assurance," we are often forced to end our care, knowing full well that a relapse is likely. This places us in the uncomfortable position of discharging our patients prematurely, rather than face a peer utilization review, which may effectively end our treatment despite our best recommendations.

The solution lies in understanding where insurance responsibilities end and providing consistent treatment which conforms to accepted parameters. In doing so, we are able to justify clearly our claim to supportive care management for our patients. There are really few gray areas, and for the provider, there is no excuse for not having full understanding of the "rules of the game." This includes having a working knowledge of the guidelines for providing ongoing management.

For the chiropractic doctor, there is really no such thing as "as needed" (pro re nata) care. To most insurance carriers, such treatment is lumped together with other bad words like "maintenance," which is not compensable under the patient's personal insurance policy, workers' compensation claim, or motor vehicle benefits. Maintenance chiropractic care is a philosophical tenant, and while many of us understand the benefit of periodic adjustments, such treatment is clearly not intended to be part of a health care package. (When an insurance policy is written that provides for "maintenance chiropractic care," please let me know!) To a peer reviewer, the revelation that treatment is "maintenance" will result in an immediate determination that care is not reasonable or necessary. There is no quicker way to lose a peer review.

"As needed" or "PRN" care indicates to an insurance adjuster that the patient will return when there is an increase in symptoms. According to many current state laws governing reimbursement, the carrier is not responsible for ongoing bills once it is determined that the patient's injury has achieved maximum therapeutic benefit. Therefore, unless your patient is continuing to make therapeutic gains, your treatment is no longer indicated. This is an important point, as it can be unsettling to the patient and doctor when they discover that despite ongoing pain, the bills are no longer being paid. Pain is not in and of itself an indication for continued care. Continued care is rarely reasonable or necessary if there is no objective benefit.

In contrast, supportive care is an appropriate and medically (chiropractically?) necessary component of patient management. As defined by the Mercy guidelines, supportive care is the "treatment/care for patients having reached maximum therapeutic benefit, in whom periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate.

"Supportive care follows appropriate application of active and passive care, including lifestyle modifications. It is appropriate when rehabilitative and/or functional restorative and alternative care options, including home-based self-care and lifestyle modification, have been considered and attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs the benefits (i.e., physician dependence, somatization, illness behavior, or secondary gain)."1 It is important that you, the practicing doctor, have a firm understanding of what this guideline means and how it relates to your everyday practice.

Notice that supportive care comes into play only when a patient has achieved maximum therapeutic benefit. It would not be considered appropriate to initiate supportive care in a case in which the working diagnosis had resolved or had yet to come under control. (A guideline for establishing "maximum therapeutic benefit" has been suggested as three successive re-evaluations in which no further progress has been made.) A patient whose condition continues to improve requires active treatment, while a resolved condition should prompt a release from care.

What's more, supportive care is only established under specific conditions. These conditions are predicated around the presence of a "progressively deteriorating condition." The Mercy guidelines assert that "periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate." From a utilization review standpoint, the proof that a patient cannot sustain therapeutic gains can only be demonstrated through periodic withdrawals from care, along with detailed documentation which clearly supports a subsequent regression in patient status.

Many practitioners, in an honest request for supportive care, simply do not provide the documented evidence which supports their case. Documentation in these cases is paramount, especially since claims adjusters continually look for reasons to deny treatment. While the need for ongoing chiropractic care may seem justified to the doctor and patient, it is impossible from a third party's perspective to grant such care when there is a lack of appropriate note-taking.

It is obvious, therefore, that establishing the need for supportive care requires a deliberate tactic on the part of the treating doctor. Patients who have reached maximum improvement and have been withdrawn from care should have specific notations made in their files, clearly delineating the end of treatment and the fact that a clinical withdrawal from care has been attempted. Then, if a patient contacts the doctor about increased problems, documentation from that file can be presented, providing evidence of a condition that has "deteriorated." This requires diligent note-taking on the part of the doctor, including objective assessment, which is being increasingly relied upon in this age of utilization review.

The sticky situation, of course, involves those cases which do not reflect an objectively deteriorating condition. Many reviewers, for better or worse, consider conditions which might require supportive care to be those which involve unstable biomechanical injuries, disc herniations, motor or sensory loss, or post-surgical management. Therefore, patients who have suffered a cervical soft tissue injury may continue to experience significant pain, yet not qualify as a supportive care case. This is a result of the assumption that while pain may be present, there is no progressively deteriorating condition. The presentation of uncomplicated soft tissue injuries, without documented objective deficits, makes it difficult to argue for supportive care, regardless of the pain involved.

When these cases arise, even better record-keeping is required. For example, I have seen cases granted supportive care for soft tissue injuries which are hard to objectify. These doctors have spelled out their rationale and treatment regimens in a detailed and forthright fashion. They clearly provide justification for their position and make it obvious to both the claims adjuster and the peer reviewer why they are doing what they are doing. While you probably will never convince a claims adjuster, a good reviewer will see that you're providing quality care. Remember, it's up to you, the doctor, to prove the case.

Another component of supportive care is the frequency at which these patients are treated. It is generally accepted that a patient who is under supportive care requires only periodic care to "support" their condition and prevent deterioration. These patients generally are unscheduled and contact the office only when they're having a problem. Frequently, doctors are surprised to see their cases denied, believing they are only seeing the patient once or twice a month as needed.

A review of treatment, however, shows that the patient is scheduled every other Friday, or the second Thursday of each month. This type of treatment, while infrequent, is still regimented, and thus not in accordance with practice parameters for supportive care. Supportive care is also about case management, not just the frequency of patient visits.

The rationale behind supportive chiropractic care, therefore, is fairly clear. As managed care continues to make attempts at cost-containment, it becomes more important for practicing doctors to have working knowledge of treatment guidelines. This includes the elements which make up the protocol for supportive care. With careful documentation and proper patient management, our patients can continue to receive the necessary, ongoing care they deserve. Reference

1. Haldeman, et al. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Proceedings of the Mercy Center Consensus Conference. Aspen Publications, 1993:124.

Steve Freeman, DC
Philadelphia, Pennsylvania
Tel: (215) 824-2810
Fax: (215) 824-2868

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Dynamic Chiropractic
March 9, 1998, Volume 16, Issue 06

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