Auto PI - Denied Chiro Claim

[platmedrec]

We have a patient that we treated for five month due to an auto accident.  She has a balance of about $2100.  We had the patient set up a med pay claim with Geico, she signed a lien and we have a credit card auth on file for any remaining balance. 

Today I received a letter from her medpay adjuster that states "We had the medical bills and records reviewed under a PEER Review.  The findings of Dr. Bigshot appears that Patient has been having Major back complaints for over a year which may be caused by stress.  Unfortunately we will be unable to honor your claim.  Please contact the patient directly to arrange other means of payment."

Patient was not treated at our office before the accident, so obviously they requested prior medical records from a provider we did not know about, however on our intake paperwork patient states she has had pain related to endometriosis and abdominal pain but indicated all back pain began after the accident and all this was sent along with our bills/records.

My question is do we have any grounds to appeal this with Geico or is the patient going to be stuck with a $2100 bill?  Is there any way to protect ours office from claims like this in the future?

Thanks in advance!!
Cara

[DMK]

Sounds like the patient will have to sue their own insurance company.  This isn't the first time this has happened and won't be the last.  The patient needs to state very clearly that the PEER doctor didn't examine her and can not make medical decisions without seeing her.  The insurance company can make her go to their doctor for an independent medical evaluation, and she must go. 

Also, and this is VERY important. The chiros notes MUST be good.  It can not be a check the box system.  Notes should be transcribed (not handwritten unless they are VERY legible) and contain all the parts of PART or SOAP, they should be SIGNED for each date of service.  The initial exam should be outlined specifically with findings and any x-ray or MRI reports should be included.

If the patient had previous back complaints, the chiro should only treat and bill the PI until the patient is back to where she was prior to the accident.

I'm sorry for your trouble, GEICO is usually very easy to deal with.  But also understand that chiros notoriously overtreat and overbill when it's a PI since it's 100% money.  (My husband is a chiro, so I'm not bashing all chiros, but you know who they are!)

So, basically, appeal from your end with GOOD documentation, and MAKE the patient be proactive with her insurance company.  Otherwise she will have to pay your bill as she agreed.

[platmedrec]

Thank you!

The patient needs to state very clearly that the PEER doctor didn't examine her and can not make medical decisions without seeing her

I think this will be very valuable!

I have never had this trouble with Gieco either, but I understand your point about chiros that overtreat.  I really don't think that is the case with this patient, but I have seen it before when I was at other billing service.  :/  It's too bad a few ruin it for the majority of chiros who just want to get the patient feeling better, not "stick" it to the insurance companies. 

We'll  see how this appeal goes.
Cara