By Cassandra Roberts,Young Conaway Stargatt & Taylor LLP
Last week the IAB released the decision in Francisco Irizarry v. Christiana Care Health Services, IAB #1294065 (10/14/09) reversing a UR decision below, in which Dr. Peter Bandera charges that were denied on UR were deemed to have been withheld wrongfully.This case is very interesting in that the Board noted that the wrong Practice Guidelines were essentially applied in the sense that "the Guidelines for low back treatment preliminarily state that the Guidelines that limit treatment are not meant to apply to post-op rehabilitation and work conditioning."There is much other commentary criticizing the UR review in this case which I will leave you to review on your own.Much of the treatment was similar to that which was disallowed in the Hairston case which I reported on a few weeks ago.
Dr. Bandera is just the talk of the town when it comes to "controversial" treatment although I must say, he was vindicated in this IAB ruling.The Irizarry case is a little gem of a decision in that it shows the claimant bar where to overcome some UR hurdles and it is a cautionary tale for the defense bar and the insurance industry in terms not having a "knee jerk reaction" to some of the billing practices.The real lesson learned here (in the opinion of this humble writer) is that there are far more loopholes with these Practice Guidelines that one might have anticipated.Limits on care? Yes. Well, maybe.One set of Guidelines for acute care.Another for chronic pain and a whole new set of treatment is allowed.Post-operative rehabilitative care needed?Just come on down!Make sense?Sure, depending on who you talk to and who is footing the bill.