Here is the history of how Functional Diagnostix, Inc. was able to turn a flat denial from an insurance company into the ability to access additional treatment that will return your patient’s level of function to Pre-Injury Status or Maximum Medical Improvement (MMI)… simply by clinically documenting significant objective deficits.

Preface:

Even though this particular incident relates specifically to a Physical Therapist… it applies equally to all healthcare provider disciplines.

The insurance industry does not discriminate against any specific provider discipline… they don’t… it is illegal.

The insurance industry requires proper documentation of Medical Necessity and Outcome Assessment in order to be eligible for insurance reimbursement benefits.

A very well known leader in the insurance industry submitted a letter of denial to a Physical Therapist who had requested an additional six visits for her patient.

This particular insurance company allowed an initial twelve visits based on the diagnosis on record.

The PT’s patient was responding as expected to the treatment plan, yet the insurance company denied the request for the additional six visits… sound familiar?

“The request for additional physical therapy is denied since there are no significant objective deficits in the submitted treatment plan and it was determined that the patient can now transition to a home exercise program”… end of story? No! This is only the beginning!

Allow me to focus on the key elements of this denial statement. The request for additional physical therapy was denied since there were no significant objective deficits in the submitted treatment plan. Yes, it’s that simple! If the Physical Therapist would have documented the significant objective deficits, the additional visits would have been approved for reimbursement and the patient would have experienced maximum benefit from the additional treatment.

DEFINITIONS:

Objective - Information relative to the patient’s condition obtained by patients history, physical examination and assessment, and clinical test results.

Subjective - Information obtained from the patient’s perception of their condition… (in other words… their opinion).

The insurance industry will no longer accept any subjective opinion as medical necessity… they want significant objective deficits based on clinical test results, and they’ll pay for it… here’s proof!

My action response to the infamous letter of denial letter was as follows.

Significant objective deficits are only obtained from clinical testing. So, clinical testing I did. At the time, the only clinical testing equipment I had access to was an old muscle strength device (w/o software).

I scheduled an evaluation of this patient, with the PT present. We were literally guessing as to what, and how much information would be appropriate.

We performed five bilateral muscle tests in order to establish significant objective deficits.

I spent six hours at a word processor compiling the test results into an official looking clinical report which included these three categories; strength – endurance – power.

I reported these findings as:
    Percentage of Strength Loss – Right or Left
    Percentage of Endurance Loss – Right or Left
    Percentage of Power Loss – Right or Left
These are, in fact, the required significant objective deficits.

I filed an appeal to the denial and submitted my reports and they immediately reversed their denial and approved the six visits. It gets better!

Two weeks later, I retested the patient in order to establish positive outcomes, submitted the Outcome Assessment report and asked for an additional twelve visits.

They were approved without question! In this case, we were able to secure an additional eighteen visits for this patient, which was adequate to return her level of function to Pre-Injury Status.

Today, we are still successful in acquiring additional medically necessary services as a result of this software's clinical documentation of Medical Necessity and Outcome Assessment.

Dr. William C. Wetmore
Provider Compliance Consultant
President & CTO - Functional Diagnostix, Inc.