What the statutes mean

The independent medical exam law only applies to group health plans. It does not apply to worker’s compensation (which has its own rules for determining medical necessity) or care related to property casualty claims (including auto accidents). In addition, it does not offer protection to patients or chiropractors whose coverage is through a managed care plan. Each managed care plan has its own method for determining the conditions under which it will pay for services.

These laws provide important protection to chiropractors and their patients when group health carriers refuse to pay for their care. Insurance companies must do more than send an explanation of benefits (EOB) when they believe that care was not “ medically necessary”. First, a decision regarding medical necessity must be made by a chiropractor. If the insurer accepts their chiropractic consultant’s recommendation, they must provide the patient and the treating chiropractor a written statement that contains all of the following:

•A detailed clinicalexplanation of why their care was determined to be “not medically necessary”. They must provide a clinical explanation and they must print the language in the patient’s insurance policy that supports the decision.

• Notice that an independent evaluation has been conducted under s. 632.87 (3) (b) 1.

• The name of the treating chiropractor.

• The name of the patient.

• An insurance company must have an internal appeal available to a patient and a description of the internal appeal process must be included in the notice that is sent to the patient.

• Notice that that the patient may request an internal appeal of the insurer’s decision. The patient, or the chiropractor on behalf of the patient, must make the request within 30 days of receiving the notice.

• The address to which the patient should send the request for an appeal.

• A list of the clinical records and documents that the chiropractor who made the decision reviewed as part of the independent evaluation.

The law also forbids a chiropractor that does reviews for an insurance company to be paid a percentage of the amount that he or she saves the insurance company.

Practical advice

It is not necessary for the insurance company to provide the name of the chiropractor that actually performed the review. While some insurance companies provide the identity of their reviewers, others refuse. They claim that since the chiropractic reviewer is providing the service for them, the reviewer is acting as their agent or employee. As the insurer they have full responsibility for the decision made by their reviewer so they do not believe there is any reason to reveal the identity of the reviewer. This policy also allows the reviewer to hide behind the insurance company.

Many insurance companies send EOB’s that use standardized ANSI codes to explain the reason for rejected services. This may be the insurer’s method of communicating that they would like the office staff to send clinical records documenting the need for the services. This administrative is used because chiropractors and their staffs do not insist that insurance companies follow the law.

When a chiropractor receives an EOB with a “medical necessity” denial they should send the insurer a form letter with a copy of this law requiring a reasonable explanation for the decision. This would require insurance companies to change their procedures and ask for clinical records earlier in the process if they are needed and would allow chiropractors to target their response to the specific concern raised by the reviewer.

Statutory excerpts

632.875 Independent evaluations relating to chiropractic treatment.

632.875(1) In this section:

632.875(1)(a) “Chiropractor” means a person licensed to practice chiropractic under ch. 446.

632.875(1)(b) “Independent evaluation” means an examination or evaluation by or recommendation of a chiropractor or a peer review committee under s. 632.87 (3) (b) 1.

632.875(1)(c) “Patient” means a person whose treatment by a chiropractor is the subject of an independent evaluation.

632.875(1)(d) “Treating chiropractor” means a chiropractor who is treating a patient and whose treatment of the patient is the subject of an independent evaluation.

632.875(2) If, on the basis of an independent evaluation, an insurer restricts or terminates a patient’s coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall provide to the patient and to the treating chiropractor a written statement that contains all of the following:

632.875(2)(a) A statement that an independent evaluation has been conducted under s. 632.87 (3) (b) 1.

632.875(2)(b) The name of the treating chiropractor.

632.875(2)(c) The name of the patient.

632.875(2)(d) A description of the insurer’s internal appeal process that is available to the patient.

632.875(2)(e) A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer’s restriction or termination of coverage.

632.875(2)(f) The address to which the patient should send the request for an appeal.

632.875(2)(g) A detailed clinical explanation of the factual basis and of the basis in the policy, plan or contract or in applicable law for the insurer’s restriction or termination of coverage.

632.875(2)(h) A list of records and documents reviewed as part of the independent evaluation.

632.875(3) (a) In this subsection, “claim” means a patient’s claim for coverage, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor’s professional license, the restriction or termination of which coverage is the subject of an independent evaluation.

632.875(3)(b) A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation.

632.875(4) Subject to sub. (2) (e), an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer’s decision to restrict or terminate coverage.

632.875(5) This section does not apply to any of the following:

632.875(5)(a) Worker’s compensation insurance.

632.875(5)(b) Any line of property and casualty insurance except disability insurance. In this paragraph, “disability insurance” does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage.