Cracking the Code: Navigating HEDIS, the Future of Low Back X-Rays, and a Possible Voice to Controvert

Dear Doctors, Therapists and Staff,

Ah, the joys of healthcare bureaucracy—where navigating through a maze of regulations can sometimes feel like deciphering ancient hieroglyphics (my apologies to hieroglyphics for the comparison). Enter HEDIS, the Healthcare Effectiveness Data and Information Set, a set of measures designed to keep us all on our toes, especially when it comes to determining the necessity of diagnostic procedures like low back x-rays. If you’re seeing low back x-ray denials from the likes of Blue Cross Blue Shield or Cigna read on!

First, let’s take a stroll down memory lane and uncover how HEDIS came to be. Picture a boardroom filled with suits, each one armed with a spreadsheet and a mission to standardize healthcare performance metrics. Voila! HEDIS was born—an acronym that strikes fear into the hearts of providers everywhere, like a required Part 7 of a National Board Exam (there isn’t one, but had you worried!). 

Now, fast forward to the present day, where insurance companies wield HEDIS criteria like a double-edged sword. On one hand, they claim to champion quality care and cost-effectiveness. On the other hand, they’re silently rubbing their hands together, plotting ways to restrict access to diagnostic imaging to save a few bucks. HEDIS measures are supposed to serve as a yardstick for evaluating the performance of healthcare plans. As far as specialties like Chiropractic, HEDIS holds particular significance, especially when it comes to determining whether diagnostic imaging is necessary for conditions such as low back pain. HEDIS has sparked discussions about whether there should be coverage of low back x-rays as a medically necessary procedure. According to HEDIS, the decision to cover or not to cover hinges on factors such as severity of symptoms, the presence of red flags, and the effectiveness of conservative treatment.

Furthermore, within the HEDIS guidelines it is felt that diagnostic imaging studies for low back pain that are taken within 6 weeks of the initial visit are, in essence, medically unnecessary unless there is reason for the provider to suspect something much more serious such as cancer or an infectious process. It states that most low back pain sufferers recover within 6 weeks with conservative treatment, such as exercise, pain meds and physical therapy, and that low back diagnostic imaging would serve no additional benefit.

So, what does this mean for us Chiropractors? Well, brace yourselves, because these x-ray restrictions could throw a monkey wrench into our practices faster than you can say “subluxation” three times fast (you just tried it didn’t you). Suddenly, our hands are tied, forced to rely on outdated clinical guidelines and guesswork instead of hard evidence.

But wait, it gets better. Picture this: You’ve got a patient hobbling into your office, clutching their lower back like it’s a Saturday night winning lotto ticket although without the joy. They’re in agony, begging for relief. Normally, you’d order or take a low back x-ray without a second thought, but thanks to HEDIS, it’s a game of Russian roulette. Will it be covered? Will you have to jump through hoops to justify it? Would that even matter under HEDIS protocols?

And what about patient safety! Without timely access to diagnostic imaging, we’re flying blind, unable to rule out those potentially serious underlying conditions or tailor our treatment plans accordingly. In my early years in practice I had a patient present with severe low back pain and upon taking x-rays I discovered a massive abdominal aortic aneurysm. A seemingly innocent lumbosacral adjustment could have had devastating results. Not being able to utilize diagnostic x-rays at our professional discretion is like trying to navigate a minefield in the dark—risky business, to say the least.

So, what’s a Chiropractor to do in these trying times? Well, for starters, we can arm ourselves with knowledge, staying informed about the latest HEDIS updates and advocating for sensible healthcare policies. Pay attention to denial remarks on EOBs and ERAs for diagnostic x-rays that might actually state HEDIS as the denial protocol used [it might even mention the non-use of the 6 week cooling off period]. We can also flex our collaborative muscles, partnering with other healthcare providers such as primary care providers, orthopedists or neurologists that may also be involved in a case to ensure our patients receive the care they deserve.

It’s also imperative that your examination findings and documentation be complete, descriptive and supportive of the need to take those diagnostic x-rays right away. Any doubt, any absence, any lack of evidence to support your rationale for those films and the insurance denial based on HEDIS is inevitable. 

There are other voices I would like to see speak out to help controvert systemic use of a denial protocol like HEDIS, or managed care plans that contractually deny Chiropractors coverage not only for diagnostic services, but simple examinations. I would be overjoyed if our malpractice carriers publicly weighed-in on these draconian measures by formally expressing to these insurers the importance of performing these services for the safety and protection of both patient and provider; as well as how these measures place a burden on their policyholders that could jeopardize their liability coverage should something go awry, and that could have been prevented if the diagnostic service had been performed. 

In conclusion, HEDIS may be a thorn in our side, but it’s up to us to rise to the challenge and champion the best interests and safety of our patients. So, here’s to cracking the code, navigating the maze, and emerging victorious on the other side—x-ray restrictions be damned!

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Yours in health and wealth,

Dr Art 

Dr. Arthur I. LeVine

CEO & Founder, iCollect Medical Billing Services, LLC

Past President, Florida Chiropractic Assn.,

Board of Directors, Florida Chiropractic Assn.,
Chairman, Insurance Relations Committee, Florida Chiropractic Assn.,
Co-Chairman, Government Relations Committee, Florida Chiropractic Assn.,
Florida Representative, Congress of Chiropractic State Assns.,
7027 W. Broward Blvd., #229
Plantation, FL 33317
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www.icollectmedicalbilling.com

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