Prospect Medical, PC v. PLIGA, 2011 WL 2462643 (NJAD 2011)
“Prospect Medical submitted claims for $18,168.68 for three MUAs performed on July 8, 9, and 10, 2008. That claim was amended to $18,084.34 in the arbitration that followed in the National Arbitration Forum before a Dispute Resolution Professional (DRP). The DRP identified one of the issues in dispute in the arbitration as whether the MUAs performed were reasonable and medically necessary and further noted Prospect Medical’s argument “that none of the opinions of chiropractors should be considered since they are not medical doctors and Dr. Sivendra is a medical doctor.” The DRP then reviewed in detail the protocols and standards of the National Academy of MUA Physicians (NAMUAP) regarding the clinical justification, medical necessity, guidelines for determining the necessity and frequency of MUA, the protocols for performing serial MUAs, and parameters for determining MUA progress. Applying those standards to the evidence submitted, the DRP set forth her conclusions:
Based upon a preponderance of the record evidence, I find that Claimant has failed to sustain its burden that the MUAs performed on 07/08/08, 07/09/08, and 07/10/08 were reasonable or medically necessary. Claimant’s medical records are devoid of clinical indicators which might have established the need for MUAs pursuant to the guidelines set forth by the National Academy of MUA physicians. First, the patient was found to be at MMI from chiropractic care on 10/16/07 and said opinion was upheld on 12/31/07. Second, and most significantly, there is no record of any conservative chiropractic care being performed from October of 2007 through June 21, 2008 when the patient presented to Dr. Sivendra. Yet, the protocols require that manipulative procedures must have been utilized in the clinical setting during the two to six week period prior to recommending MUA. No explanation has been provided by Claimant for this significant gap without any chiropractic treatment or any other treatment. Third, there was absolutely no evidence that the patient was experiencing intractable pain and/or biomechanical dysfunction. Fourth, there was no evidence that there was any pain interfering with the patient’s life-style. Fifth, there was no indication of spinal adhesions. Sixth, there was no indication that the patient was unable to undergo conscious chiropractic manipulations due to pain or rigidity. Seventh, there was no suggestion that the patient was being considered for spinal surgery. Eighth, there is a lack of supportive documentation of the hips or shoulders during the initial course of chiropractic treatment with Dr. Zientak to justify MUAs to those areas. Ninth, when the patient presented to Dr. Sivendra on June 21, 2008, the patient had no complaints in the hips or shoulders and Dr. Sivendra did not perform any examination of the hips or shoulders. Finally, while Dr. Sivendra makes the broad statement that the patient had reached a plateau from treatment, there were no medical records submitted demonstrating such. In sum, the medical record evidence simply does not support the MUA services rendered based upon the accepted NAMUAP protocols and clinical justifications for MUAs. Based upon the foregoing, I find that Claimant has failed to sustain its burden that the MUAs performed on 07/08/08, 07/09/08, and 07/10/08 were reasonable or medically necessary by a preponderance of the evidence. Accordingly, the demand is denied in its entirety and there is no reason to address any of the other issues raised.”
“For the trial court to vacate the award based upon Prospect Medical’s argument, it would have had to find that the DRP committed “prejudicial error by erroneously applying law to the issues and facts presented for alternative resolution.” N.J.S.A. 2A:23A–13(c). However, the DRP correctly held Prospect Medical to its burden of proof and examined the record to determine that Prospect Medical failed to meet that burden. Although PLIGA did not refer the precertification request to a medical doctor, Prospect Medical’s claims were properly subjected to a medical necessity analysis, consistent with the Legislature’s “intent to discourage the performance of unnecessary medical services.”
“Prospect Medical filed a verified complaint and order to show cause, seeking to vacate the arbitration award and for the entry of an award of $18,084.34 plus interest and attorney’s fees, alleging the DRP committed prejudicial error.”
“For the trial court to vacate the award based upon Prospect Medical’s argument, it would have had to find that the DRP committed “prejudicial error by erroneously applying law to the issues and facts presented for alternative resolution.” N.J.S.A. 2A:23A–13(c). However, the DRP correctly held Prospect Medical to its burden of proof and examined the record to determine that Prospect Medical failed to meet that burden. Although PLIGA did not refer the precertification request to a medical doctor, Prospect Medical’s claims were properly subjected to a medical necessity analysis, consistent with the Legislature’s “intent to discourage the performance of unnecessary medical services.”
“Dismissed”
7 Responses
This is the kind of piggie wiggie garbage angers the courts and the public. The insurance industry uses the anti provider sentiment that this engenders to deny legitimate claims.
Medical providers should not perform this nonsense. Lawyers should not sue for it. The greed, laziness and incompetence of those involved has hurt everyone.
No Fault Plaintiffs’ attorneys should just say “no” to this nonsense. We did.
If chiropratic treatment really needed to be done under anesthesia the risk is not worth the questionable reward.
Now that summer is upon us I know the back yards and sidewalks at medical clinics in Coney Island, Brighton, Sheepshead Bay, etc. are filled with patients recovering from heavy doses of cheap vodka administered as anesthetic.
MUV – manipulation under vodka? Ray, your last two comments have not been too kind to your medical provider brethren. What is happening to you?
I am tired of being left with their disgusting sludge and a mop. Specifically the lower court judges who are subjected to this sewage and then I have to litigate a simple chiro bill in front of the same judge.
I also prosecuted and investigated fraud. MUA is almost fraud per se.
In this environment why do we even have MUA. What is the medical competence of those who must resort to this in order to make a living. I see a lot of M.D.s with degrees from Baja University School of Medicine or Apex Tech School of Medicine where you get your own set of tools. How stupid can you be to do this and charge for it. How dumb are you — any of you in the industry — to pay for it.
Really — it stinks from a thousand miles away. Must you pick it up, feel it and taste it to know what it is.
I have some MUA cases and am not ashamed to say so. Like anything, MUA has the potential to be oversubscribed, especially because it can be lucrative for the doctors/chiropractors. However, it can be a beneficial treatment under the right circumstances.
While I am happy to defend the benefits of MUA in the right case, I also think it’s losing ground because of its unwelcome reception among insurance companies.
Yeah my time is LACoolDude and I am not ashamed to admit I have MUA cases.
When one of the considerations is whether your mother can survive anesthesia during open heart surgery I do not see how giving such to enable chiropractic treatment can be beneficial.
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I am the author/editor of “Manipulation Under Anesthesia, Concepts in Theory and Application”, and a co-author of the original National Academy of MUA Physicians, as well as an advisory for the new American Associaiton of MUA Providers. Now that I have given you my pedigree, let me be the first to say that much of what has been said is true. Abuse is rampaint in the field of MUA and seems to have been that way since we first brought it back to life in the mid to late 80’s. That said, it has also been a life saver to many thousands of patients when properly selected, and performed for the right reason. It was never….I said NEVER…intended to be a procedure to make money from. It is not a cash cow as many believe it to be, and it is not a procedure that should be abused financially as has been the case. Thank God that is not happening as often as in the past. With the formation of the new American Associaiton of MUA Providers, strick protocols have been created as guidliens for the practice of MUA, and even stricter educational protocols have been established for those who wish to be “presenters” (teachers) of this procedure. Before the baby gets thrown out with the bath water, at least find out what is going on in the field of MUA by ligitamate practitioners, and quit basing “arbitrary” opinions on “junk” that a small percentage of abusive practitoners would have you believe is the norm. It’s not….it never has been, and to ajuticate these cases based on biased opinions is as wrong as the abusive performance and sloppy patient selection that you see in these arbitrations. Learn from the source….not from the abusive few….PLEASE! Dr. Gordon