Select Georgia Law
The scope of practice for Georgia
GA Code Section 43-9-1 (3) 'Practice of chiropractic' shall also
include peer review which is defined as the procedure by which chiropractors
licensed in the state of Georgia evaluate the quality and efficiency of
services ordered or performed by other chiropractors, including but not limited
to practice analysis, audit, claims review, underwriting assistance,
utilization review, and compliance with applicable laws, rules, and
regulations.
Chiropractic
Review Agent - GA Code Section 43-9-1
Evaluate
the quality and efficiency of services ordered or performed by other
chiropractors, including but not limited to:
Practice
Analysis
Audits
Claims
Review
Underwriting
Assistance
Utilization
Review
Compliance
with applicable laws, rules & regulations.
Board
Rule 100-17-.01 Review Agent.
(1)
For purposes of this rule “Review Agent” means any person rendering a professional
chiropractic written or verbal opinion, which has the capacity or intent of
affecting the frequency, duration, necessity, or outcome of chiropractic
treatment or patient care and who is being compensated by a 3rd party payer or
other contractual parties.
(2)
Chiropractic care shall include offering or rendering a professional
chiropractic written or verbal opinion, which has the capacity or intent of
affecting the frequency, duration, necessity, or outcome of chiropractic
treatment or patient care.
*There
are presently 16 Doctors of Chiropractic accepted by the Georgia Board of
Chiropractic Examiners as “Review Agents”.
100-7-.04
Standards of Practice
(d)
It shall be considered unprofessional conduct to deny care for a covered
condition or service by a review agent when there is a reasonable expectation
for improvement or the patient is demonstrating a reasonable rate of
improvement. A reasonable rate of improvement would be influenced by condition
chronicity, patient age, co-morbid factors, frequency of care and exposure to
activities that would impede progress.
(e)
It shall be considered unprofessional conduct to deny care for a covered
condition or service by a review agent for care to prevent the deterioration of
a condition once the patient has achieved maximum clinical improvement, if
sufficient evidence exists demonstrating that reduction or withdrawal of care
has and will continue to have a deleterious effect on the patient.
Medical
causation must be proved to a reasonable degree of medical certainty and cannot
be based on mere speculation. Cannon v.
Jeffries, 250 Ga.
When
should a review Agent be contacted?
1) When there is no clinically
significant reduction in symptoms over a 4-6 week period.
2) When there is a reduction in symptoms
with no reduction in frequency of care.
3) When there is a diagnosis in one
region but the doctors is treating more than that region.
4) When there is more than three
modalities performed in one visit.
5) When there is only passive care and
treatment for more than 4 weeks.
6) Charges for range of motion testing on
multiple visits.
7) Treatment plans longer than 3 months.
8) Fraud investigations.
9) Impairment rating given before MMI is reached.
10) TENS unit or other equipment given on the
first visit.
11) Notes do not document therapy to standards.
12) X-ray of multiple areas that have no symptoms
or redundant x-rays.
13) Little if any notes provided to document care.
14) Pre existing conditions.
15) All permanent impairment or disability
ratings.
16) Gaps or delay in care.
17) Multiple accidents or injuries.
18) Charges appear excessive.
19) Treatment of family members.
20) Digital X-ray Analysis & other “special”
testing.
21) Notes appear to be redundant or “canned”.
22) Low speed collisions with significant injury
reported.
23) Reported pain and disability is not
proportional to the documented injury.
24) Court cases
25) Depositions
26) Causation or apportionment is an issue.
27) Scope of practice issues.
28) Independent exams or records reviews.
29) Clinical correlation
30) “Unique” cases.
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