AJCC April 2000

Vermont Insurance Companies
Deny Chiropractic Use of X-ray

New insurance equality law back fires in the State of Vermont

By Jennifer Peet, D.C.

The General Assembly of the State of Vermont enacted an insurance equality law in July of 1999. The purpose of the law was to provide coverage for clinically necessary health care services provided by a chiropractor. However, the new law is not being carried out in the manner the law makers had in mind. Many chiropractors in the state of Vermont report that the insurance coverage for their patients is less than in the past. They state that higher deductibles, limited visits, pre-authorization procedures and necessary medical referrals are making it more difficult for Vermont chiropractic patients to receive care. In addition, some traditional chiropractic examination procedures like spinal x-rays are not considered necessary and are not a covered service.

Landmark™ healthcare, a company which reviews claims for MVP, a managed insurance program, states that x-rays for any chiropractic purpose, i.e. measuring a vertebral subluxation, is not a covered service (1). But they will cover a medical reason for radiographs without glitch. Landmark also requires that the patient be at least 15 years of age or else a pre-authorization is necessary for care. What the age discrimination is based on is not clear in the manual supplied to providers.

In a form letter dated January 6, 2000 to participating chiropractors, “ In reviewing Landmark’s historical data, it has been determined that the average patient receives six (6) visits over a twelve-month period. As a result, the number of visits for covered diagnosis relating to acute neuromuscloskeletal (NMS) conditions that can be rendered, without obtaining authorization has increased to UP TO EIGHT (8) over a twelve month period.” This is only after a referral from the patient’s medical doctor, over age 15 and no x-rays are taken.

It is difficult to get a medical referral. In fact, Dr. Charles Foster, President of the Vermont Chiropractic Association has compiled information from a state wide survey which indicates that only 6 out of a 1000 referrals were given without a request from the patient. In other words, medical doctors rarely determine that a patient needs chiropractic care. “Your neighbor is more likely to determine a necessity of chiropractic care than your medical doctor,” stated Dr. Foster.

Landmark™ health care guidelines states UP TO Eight visits, but a phone survey conducted by the author revealed that none of the reporting chiropractors had received eight visits although they all asked for more than eight. Most chiropractors report that they request a care plan of 12-20 visits and receive one (1) to six (6) authorized visits. Dr. Palmer Peet, reports that, “I’m a CBP® practitioner, and practice subluxation based chiropractic. Landmark™ health care guidelines want me to compromise my high quality of care to my patients. The guidelines eliminate necessary x-rays for measuring vertebral position and severely limit corrective care to one or sometimes three approved visits.”

Radiographic imaging is taught in every chiropractic college in the United States. In fact, many chiropractic techniques use the measurements taken from plain film radiographs to determine the course of correction for vertebral subluxations. Chiropractic Biophysics, Gonstead, Grostic, HIO, Kale, Aragona, Mears, Life Cervical and Pettibon adjusting procedures all utilize radiographic imaging for the purpose of analyzing vertebral position.

In reviewing literature pertaining to the Harrison Spinal Model, CBP® authors stated that in the lateral view of the upright normal posture, neither the overall sagittal curvatures of the cervical, thoracic and lumbar areas nor the segmental contributions can be determined without x-ray (2). This practice of measuring vertebral position is also used by some medical doctors. Dr H. Biedermann (2) who reported that his accuracy improved by 60% (in overall symptomatic relief) when he measured the position of the atlas before manipulation.

Insurance companies should not expect chiropractors to rely on palpation to accurately determine spinal position. Abnormal curves, bent spinous, unilateral, unsymmetrical bony protuberances are not uncommon even in the pediatric spine. For instance, the cervical kyphosis is not a normal variant even in the pediatric spine (1) and a practitioner cannot palpate the degree of deformity. Since this cervical lordotic curve is formed in intrauterine life (4) and may be damaged during the birth process, chiropractors will have pediatric cases which require a lateral cervical x-ray. Commonly, adult patients present a loss of the normal cervical curve and a lateral cervical x-ray is necessary to determine the severity and the method of correction. The use of x-ray is not new to the practice of chiropractic. B.J. Palmer first used x-ray in 1910 initially as a tool to determine the accuracy of spinal palpation. Later, it was determined by followers of B.J. that spinal palpation was not as accurate as utilizing radiographic imaging.

Diagnostic imaging represents an integral component of chiropractic practice. This is evidenced by the widespread presence of plain film x-ray equipment in chiropractic offices and the increasing utilization of more advanced imaging.. (5)

Another Vermont chiropractor, Dr. Stephanie Marko states, “ I applied to MVP managed care as a provider and my application was denied because they said I see too many patients a day and I x-ray my patients to measure alignment.” Dr. Marko further stated that she does not plan on reapplying because 50% of her practice is under the age of 15 and would not have proper coverage. “ I do not feel that the care I could give my patient would be safe under their guidelines.”

Landmark healthcare is not the only insurance reviewer that is making it difficult for chiropractic patients. Other managed care systems have also instituted some unsafe parameters that greatly limit the quality of chiropractic healthcare to the public. If the patient, regardless of age needs x amount of visits to correct their vertebral subluxations and the insurance company reduces that amount by 1/2 or more, it is not in the best interest of the patient, it is in the best interest of the insurance company’s finances. “ I feel that my job billing insurance companies on behalf of our patients has become a great stress to myself and the patients. There is so much red tape and paperwork that it has doubled the amount of time I spend billing. The patient’s are never sure if they will be covered because the insurance company always looks for a way out of paying. The bottom line is some of the insurance companies and HMO’s are compromising patient care,” explained Mrs. S. Bourne, chiropractic insurance specialist in a recent phone interview.

Some of the Vermont chiropractors thought the insurance coverage in the state would increase if they changed the existing law to be neuromuscloskeletal. It didn’t. Now the insurance companies in the state think that back pain is the chiropractic specialty and they think they can reject any other reason for chiropractic care. Don’t let this happen in your state. Don’t sell out the chiropractic principle to gain access into a managed healthcare system. Now we have a limiting neuromuscular law and a managed health care system in the state that is unsafe for the public.

References

1. Per phone conversation with chiropractic consultant.

2. Harrison DE, Harrison DD, Troyanovich SJ, Harmon S, A Normal Spinal Position, Its Time to Accept the Evidence. JMPT 2000, in press.

3. Biedermann H. Kinematic imbalances due to suboccipital strain in newborns. J Manual Med 1992; 6:151-156.

4. Bagnall KM, Harris PF, Jones PRM. A radiographic study of the human fetal spine. J Anat 1977; 124:791-802.

5. Kent C, Plaugher G, Borges D, Borges K, Steiner DM, Cichy D. Diagnostic Imaging. Pediatric chiropractic. Williams and Wilkins 1998.