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Chiropractic Utilization Review Laws

Utilization review laws make sure that patients receive only the appropriate and necessary medical treatment and procedures. The utilization review process involves comparison of requests for medical services to the established treatment guidelines that are determined to be appropriate for said services and issuance of recommendations on what are deemed to be appropriate medical services. The process varies by state, and, in the case of chiropractors, it serves as a way for these practitioners to undergo peer review to ensure that their services comply with laws, rules and regulations.

  1. Protecting the Patient

    • Utilization review laws are a means of evaluating the quality of medical services ordered and performed by a chiropractor to make sure that such services are justified. Chiropractors are required to keep accurate documentation, which is viewed as vital for patient protection. The process ensures that a patient is truly receiving the care chiropractors claim they are providing and that the patient doesn't undergo unnecessary treatment or receive superfluous services.

    Workers Comp and Personal Injury Cases

    • Because utilization review laws also take into account state law, they vary slightly by state. In South Dakota, for example, Chiropractic Associates, Ltd. does concurrent utilization reviews for workers compensation and personal injury cases. The firm tries to return the results of the review to its patients within one or two days.

    What If Medical Services Are Denied?

    • If the utilization review determines that medical services are not necessary and therefore not covered by insurance, then the chiropractor or appropriate claim manager can request another review. While protecting the patient is much the main reason why utilization reviews are necessary, these laws are also in place to ensure that no misappropriation of funds occurs, that is, proper reimbursement is in place.

    Chiropractors Are Also Protected

    • The utilization review laws make it clear that claims cannot be denied simply because the medical practitioner providing treatment and medical services is a doctor of chiropractic. If an insurance company would not deny the same claim from a medical practitioner other than a chiropractor then the company cannot deny it simply based on the fact that the practitioner is a chiropractor.

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