07/13/2010 11:39:00 AM EST
Rubbed the Wrong Way? DE IAB rules massage therapists cannot piggyback on chiropractor's provider certification under Section 2322D
In the latest and greatest of Delaware IAB Utilization Review appeals, a further refinement of law comes out of the case Andrea Tullock Grulke v. Amazon.com, IAB # 1334951 (7/8/10), a decision authored by that scholar among men, Chief Hearing Officer Chris Baum. Grulke involved an appeal taken by the claimant relating to treatment rendered by Dr. Arnold Glassman (physiatrist), Dr. Mark Farthing (chiropractor), and Dr. Brian Chandler (chiropractor). The UR had certified no treatment rendered by Dr. Farthing, and certified six treatments each with Drs. Glassman and Chandler as conforming to the Delaware Health Care Practice Guidelines.
The treatment rendered by Dr. Glassman was awarded by the Board, along with the treatment rendered by Dr. Farthing, and merits little discussion for purposes of this commentary. The Board disallowed some treatment billed by Dr. Farthing for "extraspinal manipulation" since this was a low back injury and no one could explain exactly what was manipulated as part of this care.
Interestingly, the Board found that while the Dr. Farthing records, in isolation, might have raised a question as to what level of improvement in function was achieved by his modalities, the care rendered concurrently by Dr. Glassman was efficacious and returned the claimant to a work capability status. Looking at the care of the two providers in tandem, the claimant's pain level decreased from a scale of 8-9 to 2-3 in a period of a few months, and in 7 months the claimant was able to return to work without restriction.
The Board thus stated, "It is difficult, when two providers are providing care to a patient within a single practice, to separate out what improvement is coming from which treatment......The Board is satisfied that the documented improvement in claimant's condition justifies the treatment she received at Dr. Glassman's practice, which (with one exception discussed below), include the chiropractic care rendered by Dr. Farthing." That is what I would call Piggyback #1. And that's not even the "piggyback" that inspired today's blog"........
Now for the nugget of law worth taking out of this case. Which will bring us to Piggyback #2...... Dr. Chandler and his massage therapists. If you are into visuals as a means of learning important information (I am), think of this as the "piggyback ride" that tripped and fell.
The employer challenged Dr. Chandler's chiropractic care on the basis of non-compliance with the Health Care Practice Guidelines (it duplicated that done by Dr. Farthing and exceeded the allowable number of visits).
More importantly, the employer took issue with the massage therapy rendered at Dr. Chandler's facility not only on its merits but also based on the proposition that the massage professionals were not certified under 19 Del. Code Section 2322D(a)(1). The language of the statute mandates that all providers within the jurisdiction of this State become certified or obtain pre-authorization from the carrier if the provider wishes to pursue payment under the Delaware workers' compensation system.
Dr. Chandler argued that he is a certified provider and these services were rendered under his direction. That said, he did not perform the actual massage. Bottom line: this was not a good day for Dr. Chandler-- the chiropractic care he did render himself was deemed not reasonable or necessary and there is a comment that one month of care actually increased the claimant's pain level. Moreover, the Board ruled that the massage therapy was not subject to payment due to the lack of provider certification. Certification cannot be piggybacked. Hope the docs are reading this.
Best regards from under my umbrella,
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