Other Articles – Page 4 – The American Chiropractor

Look Closer: The Answer May Not Be Obvious

:dropcap_open:E:dropcap_close:ven with everything we do in the evaluation process of our patients, sometimes outside forces like activities of daily living, job, family and financial stress can complicate the presenting vertebral subluxation complexes and its resulting signs and symptoms. Sometimes even the littlest postural changes can affect our outcomes.

When we conduct our evaluation and management of a patient, we benefit from a thorough history based on a review of the patient’s case history or other admitting information that we request the patient to fill out. This is followed with a one-on-one consultation to review the case history where we ask additional questions to further assist our decision making. This history covers the requirements of chief complaint, history of present illness, review of the symptoms and past family and social history.

Then we perform the appropriate examination that we feel clinically is necessary to provide us with needed information in evaluating posture, ranges of motion, functional movement patterns, palpation findings, orthopedic and neurological findings. We also have to take into consideration that documented information is required to meet the billing requirements for the level of E&M that we feel is appropriate for billing purposes.

Using a digital foot scanner to evaluate the three arches of the feet to establish the patient’s pronation index will determine if he/she may benefit from the recommendations of stabilizing orthotics. Evaluation of the patient’s gait cycle using a system of analysis provides us a baseline of the different phases of the gait cycle to compare both the right and left sides. If the patient is a runner, we should conduct the analysis in both the walking and running phases. We may go as far as asking our patients about activities of daily living or a description of their job duties. How much information you feel you need to obtain through the evaluation and management process to help you with your level of medical decision making is totally based on your clinical judgment. Just keep in mind that you must always obtain enough patient data to support the level of E&M for which you are billing.

Ms. W. is a 28-year-old runner who runs an average of five miles, four to five times a week. She has been under our office’s care for the majority of her adult life. She first consulted our office with complaints of low back pain and chronic Iliotibial Band Syndrome. Following a treatment plan of chiropractic adjustments, core strengthening exercises, and stabilizing orthotics, Ms.W. responded very well and now enjoys the benefits of a wellness lifestyle. Recently, she began experiencing pain in the right shoulder area which was about three to four weeks in duration. Pain is more pronounced on the posterior side. She describes the pain as a 5-6 on a scale of 10. She also notes it develops during her run and is usually gone the following morning.

There is no history of trauma or other known reasons for the pain. We conducted a re-evaluation of Ms. W., which included a new digital foot scan (it had been three years since her last pair of new stabilizing orthotics) and a new gait analysis for both walking and running since the pain comes on while she is running. Nothing major is derived from our re-evaluation, but we begin adjusting the right shoulder. After several weeks of treatment, no noticeable changes have been noticed within the shoulder. It has improved slightly, but the pain still flares up each time she runs.

:dropcap_open:I asked her how long she had been carrying the water bottle while she was running.:quoteleft_close:
One evening after work I drove over to see my good friend Dr. Knight, who practices 12 miles west of me, for an adjustment. I notice my patient, Ms W., is out ahead of me on this country road. Realizing it is her, I stay some distance back to see if I notice any asymmetry in her gait that we did not pick up on the treadmill. What I did notice was how she was flaring her right elbow and how she was holding it in an abducted posture. I then noticed the culprit that was causing this abnormal posturing. It was a water bottle! When I finally pulled up beside her I asked how her shoulder was feeling and she mentioned it had been getting tighter and sorer over the last mile.

I asked her how long she had been carrying the water bottle while she was running. She told me she had been doing it for about a month since her belt she normally wore that carried her water had broken. As she was explaining it to me you could see a quizzical look come over her face. She asked me, “Do you think my shoulder pain is caused from me carrying the water bottle?” I smiled and said, “Let me have your bottle, finish your run and I will see you tomorrow!”

We all know that ADLs and prolonged postures can be major causes that slow the healing powers of the body. As our patients enjoy the great benefits of a chiropractic lifestyle, through the many services that we can provide them, we must always consider the not so obvious when it comes to our patients!

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

Create Your Own Stimulus Plan

:dropcap_open:T:dropcap_close:here is no doubt that obtaining $44,000.00 from the government is very enticing. In this hard economy, who would say “No” to such a gift? A gift? Well, not exactly. If you are interested in Electronic Health Record software programs, you already know that doctors will need to meet all the necessary meaningful use objectives in order to receive any incentive payments. On the Center of Medicare and Medicaid Service (CMS) website (www.cms.gov), there is a section called “Attestation”.

Under that section, the CMS answers a few potential questions you may have. One of them is: “Will CMS conduct audits?” The answer is clear: “Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program may potentially be subject to an audit.” And then they explain how to be prepared for an audit. In the best case scenario, where you do your very best to meet all the conditions, where you keep your documentation at the best of your knowledge and where you keep your office legally crystal clear, an audit is never fun.

And if the auditor finds something wrong, you are the responsible person, not your software provider. You might not be very excited to do all the necessary work to meet all the meaningful use objectives and you probably do not wish to get an audit either. If this is the case, why don’t you create and implement your own stimulus plan? If you decide to compete with the government by creating your own stimulus plan, not only will you not have the hassle of implementing a fully certified software and showing all the meaningful use objectives that the government is imposing, but you may be able to receive substantially more than $44,000.00 over a 5-year period and have much more free time for yourself and your family. One size does not fit all. Many chiropractic doctors do not want to do their stimulus certification and do not want to go through unnecessary audits. Right now, it is only a very small percentage of eligible providers who are registered to do their stimulus certification. But don’t worry, there are some good alternatives for all other doctors. There are many recipes to create your own stimulus package. Planning, organization and perseverance are the keys to success.

Planning

In all new projects, good planning is mandatory. What do you want to achieve? How much revenue increase would you like to get? How much growth are you looking for? The $44,000.00 payment the government is offering over 5 years represents only 3.5 adjustments per week (at $50.00 each). This is not much. Don’t you think you may increase your office by 4 visits per week if you are serious about it? I am sure you can. Let’s say, as an example, that you see 100 patients per week. You may set up a goal where you will see an average of 125 patients per week within 3 months from now. Let’s beat the stimulus package by 21 visits per week. Is this realistic? Absolutely.

Not only are these achievable numbers but this will probably be easier than you think to achieve. As a second goal, would you like to spend more time with your patients on each visit? And, as a last goal, recoup 4 hours per week and spend that time with your family. This does not seem to make sense, right? How can you see 25% more patient visits, spend more time with your family and spend more time with your patients? The answer is Organization. By the way, 21 visits per week at $50.00 each, 50 weeks per year for 5 years amounts to $262,500.00. This is almost 6 times the entire government stimulus package.

Organizing

:dropcap_open:You don’t need to use a certified software program to implement all the meaningful use objectives.:quoteleft_close:
In many chiropractic offices, organization is the weakest part of the entire business. This is where information technology will be your best friend. The best and easiest patient growth is through the actual active patients referral. If you spend less time in administrative tasks and use that valuable time educating your patients, you will definitely increase referrals. Increasing referrals means more patient visits. A full automated system will reduce your administrative tasks, will speed up all your processes and will provide, at a glance, all the necessary information needed to provide the greatest care to your patients, in less time.

Searching for a paper patient health file does not help any patient in his care. If the system you are presently using has a good statistic module, use it. Find out how many patients have left your office without any other appointment and have a list of who they are. Are they really done with their care or are they just on the edge of dropping chiropractic? These are only a few very simple examples of how good organization, using great information technology, will make it easy for you to reach your goal.

Persevering

There is no use putting anything new in place if you do not persevere. If you implement a new procedure, believe in it and be patient. Success comes over time. Just keep doing it and you will see results. Perseverance is probably the hardest thing to achieve. Implementing something new takes you out of your comfort zone. If you keep persevering, your new procedures will eventually become your comfort zone.

This is a brief description of how to create your own stimulus package and how to succeed with it. You don’t need to use a certified software program to implement all the meaningful use objectives. As an example, you can record your patient smoking status in almost any software program if you think this information is useful to treat and help your patients.

Creating your own stimulus package may have many advantages over the government incentive program. You may be able to generate much more income, without having to go through the CMS registration process, or through any CMS audit, etc. As far as health benefit for the patients, you may exceed the government requirements if you want to. It’s your call!

Claude Cote is an expert in EHR systems, insurance billing and chiropractic clinic management for 22 years. He has installed EHR system in 18 countries over 5 continents and nationwide in USA. He is the President and Founder of Platinum System C.R. Corp (www.platinumsystem.com). For comments or questions, please email to [email protected]

In Loving Memory: The American Chiropractor Celebrates the Life of Editor, Wife & Mother, Jean Marie Irelan Busch

After 34 years of consistent service to the chiropractic profession through her work here at the magazine, on March 29th, 2012, TAC Editor Jean Marie Irelan Busch made the transition leaving us with the honor of carrying on her legacy.

Jean, or “Jeanie” as she was called by friends and loved ones, was the loving wife of the founding publisher, Dr. Richard E. Busch, Jr. They were married 45 years, and she is survived by her six children, 14 grandchildren, and her husband. Several of her children and grandchildren continue to work at the magazine that Jeanie helped found.

Jeanie graduated from South Whitley High School, achieving the high scholastic rank of Salutatorian of her class and went on to graduate from Indiana University in 1966 with a Bachelor of Arts degree in Grammar and Theater. While at Indiana University Jeanie was a member of the Delta Gamma Sorority, was captain of the pom pom cheerleaders, taught for the National Cheerleaders Association, and was on various Indiana University steering committees, including Little 500 etc. and the I.U. Foundation. Many who have known Jeanie remember her boisterous laugh, beautiful smile, positive love of life and comforting, silent strength that those around her could sense whenever she was present.

Upon graduation from college, she traveled to Davenport, Iowa to support her husband Richard’s pursuit of his chiropractic degree at Palmer College. While there, Jeanie taught English to students at Sudlow High School. Jeanie didn’t teach school long, however, because her first child, Tracy, was soon conceived.

Jeanie returned to Fort Wayne, Indiana following the graduation of her husband from Palmer College. Before her husband, the now Dr. Busch, established the Busch Clinics, Jeanie worked as a C.A. with him at the Goeble Chiropractic Clinic in Fort Wayne, Indiana. This only lasted 2 weeks while Dr. Goeble was on vacation, and then Jeanie was blessed with another child on the way. Their first son, Rick, now Dr. Richard E. Busch III, furthered the Busch chiropractic tradition. Jeanie came on strong as a leading homemaker and mother fostering four more children: Tunde, Jaclyn, Joseph and James. Joseph, Jaclyn and Tracy are also graduates of Indiana University, with Joe furthering his education at the National Chiropractic College. Her children continue to present strong leadership for The American Chiropractor Magazine, a trait learned from their Mother.

Jeanie was also active in civic and sorority matters. In Fort Wayne, Indiana, Jeanie was active in Career Day for kids and established the category Homemaker, which was previously missing from the choices. Also, at one time she was the leader of four Brownie Troops. She was instrumental in leadership and giving her time to help her family and others with continued support for her husband in his many endeavors.

In 1978, Jeanie was called on to sell advertising in The American Chiropractor. She did so under the pseudonym Tracy Leigh. She sold an ad over the telephone on her first call! She was also one of the original editors for The American Chiropractor Magazine, with a meticulous eye for grammatical mistakes and a passion for commas, as her family liked to joke. When not editing, she was also selling advertising to many of the same companies that have become prominent supporters of the profession. From that point in 1978, Jeanie was never far away from all aspects of The American Chiropractor Magazine. When not directly involved in the delivery of the content, you could find her working on some other aspect of the magazine.

The traits that were most respected by those that knew Jeanie were her compassionate heart and tireless work ethic. Those who were around her felt blessed to have shared in her time, and those who loved her will carry her memory in their hearts.

The Safest & Quickest Way to Become Debt-Free

The Counterintuitive Formula Your Financial Advisor Doesn’t Know

:dropcap_open:H:dropcap_close:int: It’s not about your loan interest rates. As a financial advocate to Chiropractors, I deal with this issue frequently with my clients. You want to get out of debt so you can reduce your risk, increase your cash flow, and have greater peace of mind, right? Here’s the fastest, safest, and most sustainable way to do it:

1. Roll Non-Deductible Loan Interest into Deductible Loans

Assuming you have enough home equity and good enough credit, refinance your mortgage and roll as much of your non-deductible loans (credit cards, auto loans, etc.) into it as possible. The tax deduction will increase your cash flow.

2. Roll Short-Term, High-Interest Loans into Long-Term, Low-Interest Loans

Again, the goal is to minimize your interest payments and maximize your cash flow. Then, you can attack your remaining debt strategically, using your increased cash flow to eliminate one loan at a time.

CAUTION: Do NOT do this if you’re undisciplined and your spending is out of control. If you’re just going to charge your credit cards back up again, you’ll just sink deeper into debt.

3. Improve Your Credit Score

There’s a smorgasbord of companies and resources to help you do this. By increasing your credit score you get better loan interest rates, which lowers your payments and puts more money in your pocket.

4. The Secret Sauce: Cash Flow Index

Here’s where the rubber hits the road. After minimizing your payments and maximizing your cash flow, you’re now prepared to focus on one loan at a time, thus creating the “snowball effect” until you’re completely debt-free.

Most financial advisors and pundits will tell you to pay off your loans with the highest interest rates first. My advice is to ignore the interest rate and use my Cash Flow Index to determine which debt to pay off first.

To determine your Cash Flow Index, take all your various loan balances and divide each of them by their respective payments. Whichever one has the lowest number is the one you should pay off first.

For example:

Home Loan Balance: $228,000 Interest Rate: 7% Monthly Payment: $1,665 Cash Flow Index: 137 ($228,000 ÷ $1,665)	Credit Card Balance: $13,000 Interest Rate: 12% Monthly Payment: $260 Cash Flow Index: 50
Auto Loan Balance: $16,500 Interest Rate: 8% Monthly Payment: $450 Cash Flow Index: 37	Student Loan: $107,000 Interest Rate: 3.9% Monthly Payment: $650 Cash Flow Index: 165

In this example, it seems to make sense to pay off the credit card first because it has the highest interest rate. But the Cash Flow Index reveals that the auto loan should be paid off first.

The trick is to pay off debt that gives you the greatest cash flow with the least investment. A high Cash Flow Index means your loan balance is high relative to the payment, while a low Cash Flow Index means your balance is low but with a high payment. Knock out those high payments first and you free up cash to work on other debts.

In this case, by paying off the auto loan first, you free up more monthly cash, which can then be applied toward the credit card balance. Paying off the auto loan first means you can pay off both faster than if you started with the credit card.

5. Address the Risk Factor

This strategy isn’t just about paying off debt faster—it’s also about reducing your risk. Banks and other financial institutions tell you to pay off debts that lessen their risk while increasing yours. For instance, if you put more equity into your home, you are still at risk for being foreclosed on if you can’t make a payment. In fact, they may be more willing to foreclose if you have more equity in your home.

The rule here is to not directly pay down loans that keep you in the same payment (as opposed to loans for which the payment reduces as you pay them down). Rather, save the money that you would have paid on the loan balance in a separate account until you have enough to pay off the loan in full.

In those types of loans, you’re worsening your Cash Flow Index with every payment. It doesn’t give you immediate benefit, and it increases your risk by reducing your liquidity.

6. Get to the Roots

As I explain in my book, Killing Sacred Cows, without a fundamental change in consciousness regarding debt, none of these strategies will work long-term. You need to identify and solve the root causes of debt, rather than hacking at the byproducts (interest and bondage) with nothing but techniques.

Before you employ these techniques, ask yourself questions like these:

Why did I incur each of my debts? What was the purpose? Was my desire to consume or to produce?

When I incurred debt, how did I justify it?

Do I seek consolation in material things? If so, what could replace the feelings I receive from borrowing to purchase material things?

Was my debt caused by gambling—putting money into things I didn’t understand and couldn’t control? If so, what can I learn from this and how can I be wiser in the future?

Getting—and staying—out of debt requires a fundamental shift in outlook and behavior. You must change who you are, then what you do flows from that change. If you’re struggling with debt, focus on increasing your knowledge, improving your mindset, and developing your character. The practical solutions to your debt problem will naturally follow.

Garrett Gunderson is a financial advocate and the author of the New York Times, Wall Street Journal, USA Today, and Amazon bestseller Killing Sacred Cows: Overcoming the Financial Myths that are Destroying Your Prosperity.

Peer Review Abuse: A Plan for an End

:dropcap_open:M:dropcap_close:edical peer review is a process whereby doctors evaluate the quality of work done by their colleagues, in order to determine compliance with accepted health care standards. This self-regulatory procedure provides quality assurance for the medical community by fostering standardization of appropriate medical procedures and by policing caregivers who could pose risks to patients. The rationale for the process is efficiency: working doctors are best situated to judge the competence of other working doctors because they regularly see each others’ work and possess the relevant expertise to evaluate it” (New Jersey Law Revision Commission, 2004, http://www.lawrev.state.nj.us/medicalpeerreview/mprM083004.pdf).1

In a perfect world, the peer review doctor would render an opinion on the paperwork that certifies necessary care and covered issues for injured patients. Peer review differs from an IME in that there is no face-to-face meeting with the patient and no examination. The peer review doctor reviews the paperwork of the treating doctor to see if that doctor practiced within the standards of his/her license and renders an opinion about the necessity for care.

Like IME abuse, peer review abuse has gone relatively unchecked for decades, as doctors and lawyers have not focused on the solution to neutralize those reports that border on fraud or licensure misconduct language. To render a fair and balanced opinion, there are many doctors nationally who conduct very fair and ethical IMEs and peer reviews. This article is not focused on those ethical doctors who perform a necessary function in the healthcare environment.

In August of 2011, I was given a peer review report written by a chiropractor in New York who was hired by Alternative Consulting & Examination located in Fulton, New York to render an opinion on the immediate ordering of an MRI by a chiropractor, although the MRI wasn’t performed until 9 weeks post-care. The lawyer representing his client wanted my opinion on the report. The peer review doctor stated, “Because MRI’s reveal so many herniations in pain-free people, and HNP’s respond to most conservative treatments anyway, MRI findings have little if any use in determining early therapy options.” He quotes this snippet from The Journal of Family Practice. He then goes on to take various quotes from various other research journals. First, he uses The Journal of Family Practice for his lead quote in his opinion. He cites 2 authors incorrectly, as there is only one author with another rendering a commentary. The peer review doctor uses that “very limited” 1 & 1/2 page study and quotes one person’s opinion, but conveniently omits the following from the same author in the same paper: “Unfortunately there are too few studies to guide clinicians in the appropriate use of MRI in the evaluation of low back pain. Higher quality evidence is needed before firm guidance can be made for the use of MRI in the evaluation of low back pain” (Grover, 2003, p. 232).2

The same paper offers a clinical commentary by a family practitioner that states, “I find MRI useful to help tailor therapy and make decisions regarding appropriate referrals” (Grover, 2003, p. 232). The peer review doctor also omitted this in order to make one believe that his conclusion was a supported standard of care. This irresponsible type of action reminds me of the tobacco companies who attempted to defend themselves in lawsuits by quoting snippets from research and attempting to produce a global decision that cigarette smoking was safe. Although irresponsible and bordering on misconduct, it is easy for anyone to “dig up” snippets from various research articles to win an argument using limited portions of the scientific research data. The peer review doctor went on to quote many research articles of disc findings in asymptomatic patients, none of which had any bearing on the case at hand, but were all just “fluff” in an attempt to misdirect the reader. In spite of the peer review doctor’s attempt to discredit the treating doctor, this issue is a standard of care issue and goes well beyond the necessity of one patient.

The standard of care currently taught at the doctoral and post-doctoral levels is with the presence of significant radicular or myelopathic findings that corroborate with the patient’s clinical presentation of signs and symptoms, an immediate MRI is warranted in order to determine an accurate diagnosis. In the absence of either, conservative care is warranted for 6-8 weeks. Should the pain pattern persist in the absence of either a radiculopathic or myelopathic presentation, then an MRI could be considered to determine the etiology of the unexplained persistent pain. A radiculopathic or myelopathic finding may indicate a significant space occupying lesion that could signify disc issues, tumors, varices, tethered cord issues and many more co-morbidities. Without advanced imaging, the practitioner is treating an undiagnosed condition blindly in the presence of positive clinical findings and treatment may end up with the opposite effect, hurting the patient, in many cases, irreparably.

It was reported by Fish, Hisashi, Chang and Pham (2009) that “Perhaps the more meaningful portion of our study was the one in which we limited positive-MRI findings to those with major severity because lower-grade radiologic findings can be common and clinically insignificant. Disk protrusions are particularly common findings in cervical MRIs of asymptomatic patients. Mild cervical stenosis are very common, as well. Also, only significant nerve root compromises are generally expected to exert associated symptoms. It has been reported in a lumbar study that a mere contact of nerve root by disk material is usually not associated with neurogenic symptoms, whereas a compression does seem to be important in this regard. To evaluate MRIs ability to predict treatment outcome, it would be more valid to limit positive MRI findings to only those that will likely have symptomatic effects” (p. 243).3 This statement reflects the clinical standard stated previously, which is to limit an immediate MRI to a significant radiculopathy or a myelopathy.

The peer review doctor further went on to discuss studies of disappearing herniations with language that is very misleading. It is a physiological “truism” that discs shrink over time in a process called desiccation and a physiological phenomenon that begins as soon as 2-3 days post trauma. The peer review doctor’s statement, a form of misdirection and misuse of physiological facts, still does not answer the direct question clinicians have to answer, “What is the underlying pathology (co-morbidity) creating the clinical signs and symptoms?” A practitioner will not be able to conclude an accurate diagnosis, prognosis and treatment plan without an MRI in the presence of significant radiculopathic or myelopathic findings. The peer review doctor’s opinion, should it be adhered to by practitioners, will be the cause of many innocent injured patients being hurt further and possibly experiencing a delay in necessary proper treatment, surgery or proper and timely triaging in potential cancer patients. In addition, should his opinion be adhered to, it could be the cause of many doctors facing licensure misconduct issues.

Although this doctor is entitled to his opinion as a peer reviewer, his “blanket statements” are not in the best interest of the public’s health. Peer reviewers get tremendous latitude at the expense of patients and often at the expense of the doctors in trying to create standards where they have no right. Chiropractors have additional issues regarding “risk factors” that are not shared with their medical counterparts. In some of the medical literature, it clearly states that immediate MRIs are not warranted for various reasons. However, most of those authors have no training or knowledge of chiropractic care. Chiropractors usually deliver high velocity thrusts into the spine, a very safe form of care unless a risk factor is present. Although in certain tumors or central canal stenosis immediate MRIs are warranted with overt symptomatology, it would not be considered the standard of care to use MRIs as a screening process to look for possible tumors without those overt signs and symptoms, as the cost factor far outweighs the benefits. However, with the clinical presence of significant radicular or myelopathic findings, it is a current standard of care for the chiropractor to determine the etiology as the risks significantly increase with co-morbidities by delivering high velocity thrusts without first having an accurate diagnosis.

In considering the cost vs. benefit when ordering MRIs, chiropractic offers a savings of $5.74 billion over medicine and physical therapy4 for low back conditions alone, thereby validating the benefit of immediate MRIs with chiropractic care when clinically indicated. Should a chiropractor deliver a high velocity thrust into a patient with co-morbidities, including, but not limited to, the cause of radiculopathy or myelopathy and hurts the patient or delays necessary surgery or medical care in the case of tumors, that chiropractor would be subject to licensure misconduct by his/her state board for not following the standard of care.

Peer reviewers realize that doctors and lawyers often do not have the ability to understand how to use research and more often lack the ability to look up citations. This peer review doctor’s actions of partially quoting a published “opinion article” is problematic and common among unethical peer reviewers. According to a chiropractic board member in the State of New York, this peer review doctor’s lack of full disclosure is a potential licensure misconduct issue and should be reported in a complaint to the state’s disciplinary board. Unless treating doctors take the time to read all of the research quoted in the peer review reports and IME reports, this abuse will continue unnecessarily. By refuting inaccurate peer review reports with additional facts from the same research paper(s) originally used, identifying misquoted information and using research to support your care, the truth will prevail in court because of the presentation of the complete set of facts. If you add the licensure complaints to root out the “unethical doctors,” the goal of rendering and being compensated for necessary care can be achieved. In the end, the real winners are the patients being afforded necessary care to get well.

REFERENCE:

New Jersey Law Revision Commission (2004). Medical peer review. Retrieved from http://www.lawrev.state.nj.us/medicalpeerreview/mprM083004.pdf
Grover, F., (2003). Is MRI useful for evaluation of acute low back pain? Journal of Family Practice, 52(3), 231-232.
Fish, D., Kobayashi, H., & Pham, Q. (2009). MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. American Journal of Physical Medicine & Rehabilitation 88(3), 239-246.
Studin, M. (2011). The chiropractic solution for work related injuries, Recurring LBP and chronic care. Dynamic Chiropractic, 29(18), 13, 29, 34.

In Memoriam: Dr. Donald D. Harrison

Donald D. Harrison, DC, PhD, MSE, (also known as Deed by his family and early life friends) passed away 2 months ago on Wednesday, July 20th, 2011. He was 65 years old residing in Wyoming with his loving wife Dr. Sang Harrison. Due to complications from Type II Diabetes, he passed peacefully with his wife Sang, his son Deed, and his daughter Holly by his side.

Don’s Chiropractic Path

After struggling with a back injury, Don sought out Chiropractic care. He was so impressed with the recovery of his back injury due to Chiropractic care (when standard medical management had failed for him) as a patient that he wanted to become a Chiropractor. He earned his Chiropractic degree in 1979 from Western States Chiropractic College.

From 1979-1985 he and his partner at the time, Dr. Dan Murphy, owned and operated Bell Plaza Chiropractic Office in Sunnyvale, CA. In 1985 he sold Bell Plaza and moved to Evanston, WY with his Wife Sang and his boys Erin and Deed. Together, Don and Sang started Evanston Chiropractic Center (1986-1992)

At the age of 47, in 1993, Don and Sang made the decision to concentrate on spinal research and he went to graduate school and received his MSE in Mechanical Engineering in 1997 from the University of Alabama in Huntsville, and a PhD in Applied Mathematics in 1998 from the University of Alabama in Huntsville (UAH). Don had to get special approval from the UAH education board to work on these two difficult degrees simultaneously; his tenacity and unmatched work ethic allowed him to persevere.

Dr. Don’s Professional Activities and Accomplishments.

He was a Member of the Board of Directors of the International Chiropractic Association, was an ICA member since 1977, was nominated as a Fellow of the ICA (FICA in 1990), and received the ICA’s Chiropractor of the Year award in 2006. Don was also the ICA Representative for the state of Wyoming in the years 1986-1993, 2001-2004. And he was the past President of the Wyoming Chiropractic Society in the late 1980’s.

Dr. Harrison was an Extension Faculty member for several Chiropractic Colleges including: Life Chiropractic College-West, Life University, National Chiropractic College, Cleveland CCKC, and the Universite du Quebec a Trois-Rivieres.

Dr. Harrison became one of the most published Chiropractic researchers in the history of the profession; with over 80 peer-reviewed publications to his name. These publications appeared in the top physical medicine, orthopedic, biomechanics, and spine research journals around the world. Dr. Harrison was voted in as member of the prestigious orthopedic research society: The International Society for the Study of the Lumbar Spine (ISSLS).

Don’s Memorial Funds or Donations

In lieu of flowers and cards, the family of Dr. Donald Harrison has established a memorial fund in his honor to further Chiropractic education and research. Send donations to CBP NonProfit, Inc. P O Box 1590, Evanston, WY 82931-1590. Or online to donate specific numerical amounts; enter for ‘Dr. Don Harrison Memorial Fund’ in the comment box: http://www.idealspine.biz/c-25-cbp-non-profit-research-cd.aspx

Stay on Purpose: A Report from the Life West Wave Conference

Over the summer, I attended and spoke at Life West’s investiture of Dr. Brian Kelly, the college’s new president. When Dr. Gerry Clum, the retiring president of Life West, prepared to hand the reins to Dr. Kelly, he gave him some final advice: “Don’t have your investiture in August because you will have very few people attend.”

At the ceremony, which attracted more than 1,000 attendees, Dr. Clum promised that would be the last advice he’d ever give to Dr. Kelly, with a wink and a chuckle. But all joking aside, the enthusiasm at Life West Wave Conference was contagious. The event attracted students and prospective students, alumni and individuals from all corners of the world.

Even though California, the state where the event was hosted, has experienced some hard times recently, the speakers at the event offered only optimism. I heard a common theme throughout the weekend, that if you truly care about your patients, your practice will thrive, despite negative external pressures. From new graduates to those nearing retirement, every speaker was absolutely confident they were in the right profession and had a mission to fulfill.

Sometimes we get so bogged down in our daily challenges that we lose sight of the purpose of chiropractic. Impressively, it remains the number-two health profession in the world and its significance and effectiveness will transcend the barriers of insurance changes, economic downturns and more. When I started practice in 1964, the outlook for chiropractic was very uncertain. We simply kept on keeping on, and, lo and behold, these past decades have been golden in so many ways.

Those of us who have kept our patients’ welfare at the center of our mission will continue to succeed in this profession. The enthusiasm about the future of chiropractic at the Life West Wave Conference was proof of that imperative. Having people excited to catch and ride the wave of chiropractic, and always looking ahead for that next big swell is what makes our profession great.

Dr. Arlan Fuhr travels extensively to chiropractic seminars, conferences and events around the world. He will be providing his insights and perspectives from these visits as a regular guest commentator for The American Chiropractor. You can reach him at 602-445-4230 or email [email protected].

Doing the Right Thing the Wrong Way Can Cost You!

Yes, I know. Sounds strange doesn’t it?

:dropcap_open:S:dropcap_close:trange as it sounds, it is far too familiar to those of us who work with doctors on a daily basis to help improve their documentation, billing, coding and collections. We see examples of doing the right thing the wrong way every day in chiropractic clinics across the nation. It happens when doctors attempt to do the right thing in helping patients with no insurance or limited benefits by “tweaking” their documentation and coding to result in an overall lesser charge for the patient.

Be honest. Have you ever had a patient that required more than a routine workup but you used a lower level exam code because you knew they had no insurance coverage? Perhaps a 99202 instead of a 99203? No big deal right?

WRONG!

Or, as long as we are being honest, have you had a patient that you adjusted full spine, 4-5 levels, and you only charged a 98940 for 1-2 levels? No big deal right?

WRONG!

Ok, let’s try one more. How about this scenario? Have you ever had a Medicare patient that required a detailed workup and x-rays and you charged a lower level exam code or just billed for 2 x-rays when you actually performed 4, because you know Medicare doesn’t cover your exams or x-rays? No big deal right?

WRONG!

All of these are examples of down coding your services in an attempt to strike a balance between what insurance coverage may allow and what you feel your cash or underinsured patients can afford.

We all know if you don’t perform a service you should not bill for it…it is called fraud. However, few may be aware that if you DON’T report what you did and DON’T charge for services you would normally bill to insurance because you are seeing a cash patient there is also the potential for fraud because of a dual standard of care and a potential dual fee schedule.

Not to mention, down coding or failure to bill Medicare patients can be considered an inducement and subject to serious fines and penalties according to the Office of Inspector General and CMS.

The bottom line is that down coding can be perceived as illegal and inappropriate just as up coding is when it is used to allow you to bill differently based on whether the patient is insured or a cash patient. It is “gaming” the system pure and simple. It is doing the right thing to help the patient, but it is being done the wrong way and it can cost you.

What drives doctors to down coding or not charging for all their services? It’s really quite simple. There is the need to maximize reimbursements by billing your UCR fees or contract rates to insurance companies, but you haven’t found a good way to make care as affordable as you would like for your cash and underinsured patients.

So the only tool you have is to “tweak” the documentation, coding or billing to allow you to do what you would like to do. It really is that simple, but it can REALLY be very costly if you are audited!

:dropcap_open:It really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees.:quoteleft_close:

So how can you document as you should, bill as you should and code properly for maximum reimbursement when there is insurance available and still be able to help the cash patients? You MUST join and encourage your patients to join a cash discount program, commonly known as Discount Medical Plan Organizations or DMPOs.

It really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees. It allows you do what you are attempting to do now…help the cash or underinsured patients. But, with a network contract, you can do it without “tweaking” your documentation, coding and billing and you avoid running afoul of dual fee schedules or illegal inducements.

So, do the right thing! Document correctly. Code correctly. Bill correctly. And, consider joining one of the cash discount plans which allow you to “contract” with cash and underinsured patients so you can discount correctly.

The contract model is not new. The contract model is what allows you to contract with multiple insurance companies for different rates for the same codes without it being considered a “dual fee schedule”.

Cash discount plans simply provide you the protection of a “contract” and allow you to document, code and bill properly and still pass on some savings to your cash and underinsured patients.

If you are documenting properly, coding properly and billing properly, good for you! Just make sure you don’t do the right thing the wrong way by trying to use a “bookkeeping reduction” or Time of Service discount that can be open to interpretation as to what is a “reasonable” discount. Far too many clinics use these tactics or strategies improperly in trying to help cash and underinsured patients.

Most all patients are familiar with “buying clubs” like Sam’s Club and networks and they don’t hesitate to join these plans to save money! A good cash discount plan solves so many of the potential problems for you as a provider when it comes to avoiding dual fees and creating inducements. And, they really help the patient…the RIGHT WAY!

THE MAIN THING IS….THERE IS NO WRONG TIME TO DO THE RIGHT THING!

If you’re offering discounts and you are not sure you are following state AND federal rules and regulations, doing NOTHING is NOT an option! There is NO good reason to put off solving this problem when it can be fixed so easily! Take action and start looking at the cash discount plans that are available and use the one that best suits your practice.

Article submitted by ChiroHealthUSA

Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He is a former President of the Mississippi Chiropractic Association and served 12 years on the Mississippi State Board of Health. He is a Fellow of the International College of Chiropractic, as well as member of the ACA. You can contact Dr. Foxworth at 1-888-719-9990 or [email protected]

Multidisciplinary Practices Require Keen Compliance Tactics

:dropcap_open:M:dropcap_close:any healthcare providers have begun to recognize the potential benefits — in patient care and in practice growth — that can be obtained when MDs, DOs, DCs and PTs work together. By working together all participants add valuable expertise to their practices, resulting in improved patient care, convenience, and better patient service.

If you are thinking about transforming your clinic into a multidisciplinary practice — one that offers multiple healthcare and healing professions and disciplines in one legal entity — you cannot afford to be misinformed. Misinformation can lead to noncompliance. And noncompliance is something you do not want to happen.

A failure to be in compliance means that you will not be allowed to participate in federal or state funded programs; you could lose your license to practice; and you could be subject to civil and criminal penalties.

To avoid legal problems and to make sure you create a clinic that helps your patients in the best possible ways, let’s look at a number of things you should put on your checklist:

Engage a healthcare attorney. If you are considering establishing a multidisciplinary clinic, hire a healthcare attorney in the state in which the multidisciplinary practice is to provide services. State corporate laws and scope of practice regulations control how multidisciplinary practices must be formed and operated. These requirements vary dramatically from state to state. Only an attorney who specializes in healthcare can make your corporate structure complies with the law.

Take a multidisciplinary approach to compliance. Your professional support team should take a multidisciplinary approach, with non-lawyer professionals working in conjunction with lawyers. When lawyers and other professionals from various disciplines such accountants and management consultants work together, the results are excellent. The professionals from the nonlegal disciplines are typically pleased with this approach, since they no longer have to attempt to understand or interpret laws. Each specialist works within his or her expertise.

Hold proper shareholder meetings. The courts consider observance of corporate formalities as important evidence in deciding whether or not your professional corporation is 2 operating as a legal entity. Properly held meetings of shareholders and directors are the key to a formal operation. These formalities are often the source of authority for those who act on behalf of the corporation. Officers, directors and employees who act without authority (that is, without proper approval of the shareholders or the directors, properly made and recorded in the corporate minutes) may be personally liable for their acts. If your state’s legal structure requires you to form two or more corporations to establish a multidisciplinary practice, meetings must be held for each corporation. Each corporation must have two meetings: One for the shareholders to re-elect the directors and one for the directors to have a business meeting. Minutes must be taken, voted on and approved.

Review your corporate documents regularly. Your corporate documents are living entities and should not be shelved in a box but should be reviewed by a team of counselors on a regular basis to assure compliance. Your attorney should review the corporate agreements comprising your multidisciplinary practice, which describe the duties and obligations of each corporation to the other. Have your attorney check with your state to be sure that all required forms, documents, and reports are filed with the Secretary of State on a timely basis. Be sure to make your state aware if you hire a new medical director who is a shareholder. Be sure that your corporate documents reflect the new medical director’s financial contribution. Review the direction of your practice. Have any changes been made? If so, review them with your attorney to be sure that you are compliant.

Implement appropriate accounting procedures. Accounting is not just a yardstick to figure out how much money you made last year or what your tax liability is. Used properly, accounting also helps you identify trends in sales and expenditures. The ability to track and identify trends allows you to make decisions that can boost your profitability and enable you to avoid cash shortages. If you operate in a multiple corporate structure, pay particular attention to the invoicing between the companies. You must keep very careful, meticulous, well-organized records. One reason to keep good records is for tax purposes. If you ever get audited, the tax people are going to want to see invoices and receipts, not just cancelled checks. If you can’t 3 produce the invoices and receipts requested during an audit, the IRS will not be understanding about it! Be sure that your accountant compiles a quarterly audit of the documentation for funds flowing between corporations. And be sure that all charges and receipts are substantiated by invoices at “fair market value.”

Comply with Stark regulations. Under Stark regulations, physicians (including DCs) are prohibited from referring patients for certain designated health services reimbursable by Medicare or Medicaid to any entity with which the physicians have financial relationships. This law applies to virtually every multidisciplinary practice, as designated health services include physical therapy services and rehabilitation. Even referrals within the same corporate entity or partnership are subject to this restriction. As a result, unless a legal exception from Stark can be satisfied, such relationships are fraught with illegality.

Maintain an OIG compliance program. Your compliance program serves as prevention — not a panacea. Be sure that your compliance manual is up to date with your baseline audit; policies; procedures; record of ongoing training; reporting and corrective action; and ongoing prospective auditing reports. Keep your practice is up-to-date on all CPT coding changes by regularly checking updated coding resources.

Adhere to HIPAA compliance rules. Ask each patient to sign the HIPAA Notice of Information Practices and keep the document on file. Review all contracts with outside vendors and suppliers to be sure that they are OIG- and HIPAA-compliant. Check to make sure that you have HIPAA Business Associate Agreements signed for all applicable business associates to ensure that they are complying with HIPAA regulations. Remember that all new employees must sign a document stating that they have received or read a copy of your Compliance Policies and Procedures and a your Employee Office Policy. You should perform employee reviews minimally on an annual basis. Your practice team also needs feedback on how well they are carrying out their duties. Update job descriptions minimally once a year and ask affected employees to sign the updates. Keep a record of your employee reviews — even when favorable. (Employees should also sign all reviews.)

Keep a daily practice journal. This journal, kept in a bound notebook, is a detailed log of all the daily occurrences in your practice. Maintaining this journal, whose entries should be signed or initialed, is a particularly important procedure in a multidisciplinary practice. The journal includes hiring of new staff members, new equipment acquisition, equipment maintenance and calibration schedules, staff training and meetings. In a multidisciplinary practice, the team approach to care requires interaction and communication between the physicians and physical therapists comprising the practice. These meetings should occur on a regular schedule and should be documented.

Dr. Mark Sanna is a member of the Chiropractic Summit and a board member of the Foundation for Chiropractic Progress. He is the president and CEO of Breakthrough Coaching (www.mybreakthrough.com 1-800-723-8423).

Prepare for Price Hikes

:dropcap_open:Y:dropcap_close:ou can forgive Americans for being caught off guard by talk of the potential for more dramatic price increases in the coming years. For the past two decades, inflation has not been a significant concern. In only six years out of the last 20 has the inflation rate (as measured by the Consumer Price Index) turned in more than even a modest annual increase of 3 percent. By contrast, in the prior 20-year period, prices rose by more than 3 percent annually in all but one year. Annual price increases topped 12 percent in three different years during the late 1970s and early 1980s.

Are we headed for another era of high inflation? There are concerns on some fronts, particularly given rising prices for commodities such as food, metals and energy. The World Bank reports that food costs globally rose 30 percent in the 12 months ending in January 2011.While some price increases are being felt in the U.S., consumers here so far have been spared any serious impact. According to the Bureau of Labor Statistics, the price of a basket of common food items in the U.S. rose just 1.5 percent in 2010. However, the average price of a gallon of regular gasoline, according to the U.S. Energy Information Agency, jumped 18% in 2010.

:dropcap_open:Are we headed for another era of high inflation?:quoteleft_close:

The sudden focus on the risk of inflation is a surprising shift from just a few months ago, when many economists were raising concerns about deflation, the threat of prices for goods and services declining. Deflation is a sign of economic weakness. Modest inflation, on the other hand, tends to reflect a stable and growing economy. However, rapid inflation can create a real strain for consumers, businesses and the economy as whole.

Making sense of the numbers

The government reports inflation numbers every month using the Consumer Price Index (CPI). This is only meant to portray an average rate of cost increases across a broad spectrum of the economy. You may think that rising prices for food, gasoline, health care and college tuition are reducing your purchasing power more than the CPI indicates. But the CPI also accounts for other costs, such as housing, labor and services, which in some cases have been flat or declining in price in recent years.

Higher inflation in certain items, however, can have an impact across other parts of the economy. If higher prices for commodities like food and energy products persist, the effect is likely to spread to other areas of the economy where companies will be forced to increase prices as well. This can lead to more substantial hikes in the cost-of-living that are felt by nearly everybody.

Protecting your money if severe inflation returns

Faster increases in living costs can clearly create challenges for you. Here are some steps you can take now to prepare for the potential impact of higher inflation:

• Closely review your spending – now is a great time to think about your living expenses. The more you spend, the more costly life becomes if inflation develops into a serious issue again in the future. Try to find ways to limit driving to reduce gas costs. Adjust your food shopping habits to make your budget more efficient. Steps you take today will ease the burden of potential future inflation concerns.

• Consider making “big ticket” purchases sooner – buying a home or car or completing a major home project may be less expensive today than it will be in several years if inflation picks up. Now may be the time to take advantage of the purchasing power that exists today – if it fits your budget.

• Lock in low rates for borrowing – if you have borrowed money using an adjustable interest rate (many homeowners do this with their mortgage), you might want to consider locking in a low fixed rate for an extended term. If inflation does rise, it is likely that interest rates will follow a similar course. Better to lock in the lowest rates you can if it is appropriate for you to do so now.

• Don’t lock into low rates on a long-term savings vehicle – there is little advantage to putting a large amount of money into a bond or certificate of deposit for an extended period of time if it pays a very low interest rate. On an after-inflation basis, the return you earn today is nominal. If inflation becomes more significant down the road, your return could actually be negative after rising living costs are taken into account.

• Invest in assets that can appreciate in value – stocks of companies positioned to grow during inflationary periods, commodities such as precious metals, agricultural or energy investments and real estate historically tend to perform reasonably well if living costs rise more dramatically. Be certain that any investment decisions you make are consistent with your long-term objectives and your risk tolerance.

Rich Van Loan is a CERTIFIED FINANCIAL PLANNER ^TMProfessional and Chartered Retirement Planning Counselor. A graduate of Harvard University and Boston University, Rich has been helping his clients achieve their retirement, education and investment goals for over 12 years. Visit his website at www.ameripriseadvisors.com/richard.r.vanloan