Select Georgia Law
The scope of practice for
chiropractors was completely revised and updated in 2007. Within this new scope
of practice was a provision concerning chiropractic review agents. 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:
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
App. 371, 372 (1) (551 S.E.2d 777) (2001). 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
26) Causation or apportionment is an issue.
27) Scope of practice issues.
28) Independent exams or records reviews.
29) Clinical correlation
30) “Unique” cases.