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Writing a Progress Report for a Patient's Insurance Company

Kevin P. McNamee, D.C., L.Ac.

When an insurance company sends a request for patient records, health care providers usually find themselves answering questions about medical necessity. In other words, is the given treatment medically necessary to either cure or relieve the patient’s condition or chief complaint?

The patient’s health care policy coverage, in the vast majority of instances, is to either cure the condition or bring the condition to a level of maximum medical improvement also known as MMI.

Maximum medical improvement (MMI) refers to the state in which the patient’s clinical findings, both subjective and objective, have reached a plateau in improvement. The insurance company is looking for a reasonable treatment time in doing so with other treatment avenues or methods attempted. For example, many studies of recovery time from a soft tissue injury, such as a sprain and/or strain of muscles, ligament and tendons, usually resolves itself in three months. As a practitioner, your job is to reduce any residuals, get the patient back to normal activities of daily living in a shorter time. If your treatment has been ongoing for eight months and the records do not show an appreciable improvement from one visit to the next, then the medical necessity of the treatment you prescribed is called into question. Are you helping this patient or just MAINTAINING the condition? This is called maintenance care in the insurance industry vocabulary. Generally, the health insurance coverage does not include maintenance treatment; since it is not billable to the insurance company, the patient pays this directly to you.

A related term is Pre-injury Status. This refers to the patient’s physical state when treatment subjective and objectives reach a particular level before the onset of the current condition or problem.

When you receive a request for records, your goal is to show there is medical necessity for your treatments. Use the records to demonstrate that there is a reasonable expectation to see improvement in the chief complaint or problem. The best way to support this is by sending copies of your patient records. DO NOT send in your original patient records, as you are the custodian of these records. Only provide chart record copies to the patient and those parties the patient authorizes, such as an insurance company. When sending chart notes, include the initial history of the condition, the initial examination forms, your daily progress notes showing changes in the subjective and objectives, copies of diagnostic test results (i.e., laboratory tests), and the summary of your care (use the progress report form below).

800-549-5993

Copyright 2010 by Dr. Kevin McNamee, DC, LAc. Please do not duplicate in any manner.

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