Opening a New Office… How to Lower your Expenses

:dropcap_open:A:dropcap_close:t a glance, opening a new practice seems easy.  But in reality, opening a new chiropractic office can be a significant financial challenge.  Opening a new office is exactly the same as opening any other kind of business.  You will have to rent office space, buy equipment, set up a marketing plan, hire employees, and the list keeps going on, and on…  All the above tasks have something in common.  They are all expenses.  Until your new office gets in operation, you will have to face many expenses which can become very large.  You get yourself committed to monthly payments for years to come.  This can be very scary because, although you have lots of confidence, you never know exactly how open-minded the community will be for your health services.  How many patients will you have the first month?  Will your marketing plan be efficient?  What is your plan if patients are not coming in as expected to cover your expenses?  Then, you may have to face reality, which can include the possibility of bankruptcy.
walletwithmoneyThis is why you need to be very careful with your expenses when opening a new office.  There are many ways to delay some big expenses until income is coming in regularly.  Today, I want to give you a few ideas to think about that will help you lower your expenses and be even more.
Marketing and Office Location
Marketing and office location should be analyzed together.  In order to have new patients, the community has to see you somewhere or somehow.  This can be done by renting an office space on a very busy street or commercial building.  You may pay more for the rent for your office, but the traffic generated at a prime location can provide you with big savings on marketing.  If your new office is hidden somewhere else, you will have to spend much more for marketing to attract new patients.  Renting an office in a prime location is not a guarantee that people will stop in  to get health care either.  You need to have a very good strategy for your marketing and nothing should be done on a “trial and fail” system.
X-ray Machine
X-ray machines are expensive. For the first few months, you may find a nearby health office that could provide the x-ray service for you.  You can negotiate a discount price and still make a little profit to compensate your time.  This is a win-win situation for you and the x-ray provider.  When your clinic gets to the desired volume of patients and your finances get healthier, then you can buy your own x-ray machine.  If you opt for this strategy, then make sure you choose an office location close to your x-ray provider.  The closer, the better.  This will make it easy for your patients.
Chiropractic Assistant and automated Electronic Health Record system
:dropcap_open:Until your new office gets in operation, you will have to face many expenses which can become very large.:quoteleft_close:
Employees are, by far, the biggest expense for all businesses, including chiropractic offices.  The good news is that new technology can tremendously lower that expense.  Those new fully automated electronic health record (EHR) systems will make your work very easy without any assistants at all.  Not only are they fully automated and customizable, but they are very, I mean very, easy to use.  Also, some of them can be used as a free trial for a long period of time.  Let me give you a brief description on how you would operate your office with no paper and no assistant.  First, you buy two or three computers and install one at the entrance of the waiting room.  Since you may have planned a desk for your future front desk assistant, you may install a computer at this desk also.  Then, you install the last computer in your treatment room.  You give every new patient a chiropractic health card, enter his chiropractic exams in the EHR system, and set up his treatment and billing.  Believe it or not, you are ready to go.
:quoteright_open:Then, while you treat the patient, you enter the SOAP notes pressing a few buttons on a touchpad.:quoteright_close:
The Clinic Patient Flow Without Any Assistants
Every morning at the waiting room computer, you will start the waiting room management software.  Throughout the day while you are in your treatment room, patients will arrive and swipe their chiropractic card at the waiting room computer.  This action will insert the patient in the clinic flow system.  From your treatment room you will see how many patients are waiting for treatment and who they are.  From your treatment computer, you will release your room and the first patient will be automatically called through speakers to come into the treatment room.  This can be done with multiple treatment rooms also.  Then, while you treat the patient, you enter the SOAP notes pressing a few buttons on a touchpad.  When you are done, you will close the patient file and another miracle will happen.  
The billing will be automatically triggered according to what you have done and relative to his or her insurance.  Do you hear something in the waiting room?  Oh yes… on closing the file of the previous patient, the next patient is being called to come in now.  You may take patient payments and quickly enter them in the system from your treatment room.  With one mouse click, you may give him his next appointment or multiple appointments if you wish to.  Once a week, you click one button to send all the claims to a clearinghouse.  Once a week, you click another button and all the insurance payments get automatically posted in each patient file, with no possibility of mistakes.
With new technology and some ideas, it has never been easier to open a new chiropractic office at such low costs. 

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 (  For comments or questions, please email to [email protected]

Self Esteem, the Missing Link in Practice Success and Satisfaction

:dropcap_open:T:dropcap_close:he most important things in life come from inside out – happiness is inside-out, love is inside-out, health is inside-out, and indeed, success in chiropractic practice is also inside-out.

selfesteemSo, what do you need inside you to experience the level of success and satisfaction in practice that you desire? There are many qualities that figure into this equation – discipline, creativity, presence, healing consciousness, willingness to do whatever it takes, decisiveness, confidence, technical skill, motivation, passion – to varying degrees, such characteristics seem to be predictors of practice growth and development.

But there is a single attribute that seems to drive all the others, and that is self esteem. You cannot develop or demonstrate any of these other traits unless you believe yourself to be worthy of so doing. Self esteem is the foundation of all positive movement, professionally and personally, so it will help you to understand and appreciate the importance of self esteem, and the ways to evaluate your own self-image to make the most of yourself and your practice.

Dr. Nathaniel Branden, author of The Six Pillars of Self Esteem, says that self esteem is feeling “competent to cope with the basic challenges of life” and  “worthy of happiness.” He goes on to say, “It is confidence in the efficacy of our mind, in our ability to think… our ability to learn, make appropriate choices and decisions, and respond effectively to change. It is also the experience that success, achievement, fulfillment — happiness — are right and natural for us.”

Notice the impact of self esteem on your evolution as a professional and as a healer – you’ll have to see yourself as being competent to deal with challenges and being worthy of happiness to generate any personal or professional progress. Why would you work at improving yourself if you didn’t feel competent and worthy? These are the precursors to optimal performance, and an invitation to achieve at the highest level possible.

And that’s why it’s so important for the doctor of chiropractic to understand the role self esteem will play in his or her practice success and satisfaction. Let’s compare those with sufficient self esteem and those without, and note the distinctions between them, so you can identify where you are in this continuum and take the necessary next steps.

Doctors with high self esteem feel good about themselves and their work. They are proud and confident, inspired to share their ideas, and driven to provide an outstanding service. These doctors invest in themselves, through seminars, reading, online courses, coaching, masterminding, and otherwise enriching their internal maps, imprinting new ideas, constantly learning, and sharing with patients and other doctors.

Doctors with high self esteem have fair policies and effective, enforceable procedures. They are comfortable discussing finances with patients, and confront gently and professionally to guide patients toward compliance. They are neat, timely and organized, and they lead their teams with integrity, while caring attentively for their patients. They are reliable and service-oriented.

Doctors with poor self esteem, on the other hand, may feel insecure, indecisive, and weak. They resist change, are defensive, and underachieve for lack of drive to succeed, since they don’t feel competent or worthy of success.

:dropcap_open:The same thing happens when you get squeezed – what comes out is what’s inside.:quoteleft_close:

You can build self esteem by reinforcing positive habits and behavior patterns, and by establishing a constructive inner environment, so you perceive the world optimistically and respond accordingly. You can use affirmation, visualization, empowering self-talk and goal-setting to shift your self-concept, among other self-development tools and techniques. Self esteem influences every aspect of a chiropractic practice.

It encourages confrontational tolerance in asking for referrals, addressing delinquent payment or re-delegating staff responsibilities. It turbocharges your patient compliance, because patients will automatically gravitate toward and follow the recommendations of a doctor who is certain and authoritative without being unpleasant about it. And finances are managed more efficiently because the doctor and staff with good self esteem expect to be properly compensated for their excellent work, and won’t settle for less, since it would be out of balance any other way.

Like Wayne Dyer says, when you squeeze an orange, what comes out is orange juice, because that’s what’s inside. The same thing happens when you get squeezed – what comes out is what’s inside. In practice, every day you’ll need to perform professionally, charismatically, and compassionately. You’ll also have to deal with patients or staff who may need extra guidance to stay on course, families who struggle to afford the care they need, and people’s very real health challenges.

For those reasons and many more, you must feel good about yourself as a person and as a doctor to effectively handle modern-day practice. Who you are determines how well what you do works – success comes from you, not to you.  Show up as a better version of you and your patients will be better served, and  your overall practice experience will be more fulfilling.

Dennis Perman DC is co-founder of The Masters Circle, a leadership coaching, practice building and personal development company for chiropractors. The author of numerous CD albums and books, and the executive producer of TMCtv, the world’s largest online video success library for chiropractors, he has published “The Column” every week for over thirteen years. Contact him at [email protected]

Murphy’s Law (1) When Starting a Practice

“Murphy’s Law” is an old adage that is typically stated as: “Anything that can go wrong will go wrong”. When you start a new practice you’ll experience many examples of Murphy’s law. I’ve opened over 3,000 new practices. Just when I think I’ve heard them all, a new twist on Murphy’s Law comes along. Here are a few of my favorites. I offer them with the hope that they just might help you avoid getting “Murphied”.

Everything takes twice as long as you think it will – then double it.


ook at your projections … then double the length of time you’ll need to open your new practice. You’ll find that whenever you set out to do a task, something else must be done first. And if you think you don’t have time to do something right, you’ll always find time to do it over again. I’ve had many clients who tried to rush into practice. The day they arrived in town they put up their “open” sign. Unfortunately, the city noticed that they didn’t purchase their city and county licenses and closed them down. Then when they solved this problem they rushed into practice… forgetting to apply to and sign up with Medicare, HMOs & PPOs. Therefore they didn’t get paid. All that work and stress resulted in extremely little income and more stress. Trying to speed up the process doesn’t work. Unfortunately, you’ll find that out when you skip a step, it will take longer because every shortcut breeds new problems. This results in the saying, “A shortcut is the longest distance between two points”.

Don’t try to establish an opening date for your practice. You’ll never open on that date. Your opening date will occur when everything that needs to be done is completed…not until then. Remember, everything takes twice as long as you anticipate. And if you pressure yourself to open on a certain date, all you’ll accomplish is greatly increasing your stress…unnecessarily.

Nothing is as easy as it looks… nothing. EVER!

The best made plans usually go from bad to worse. Most of the time when you apply for a remodeling permit the city won’t approve it. When they do approve it they will usually change their mind. When you are ready to sign your office lease, the landlord will lease your office space to someone else. That’s Murphy’s Law.

When you cheat… you’ll get caught… KARMA

When a doctor tries to remodel his/her office without a permit, he/she will usuallly get caught. Too many times a doctor will try to save money by not paying for an architect to design his/her office to city specifications, not paying for building permits, etc. He/she is trying to outsmart the system. This doesn’t work. City codes are made to protect you and your patients. The city building inspectors and fire inspectors will notice construction going on at your office site and close your office. At this point the city will be furious at you and will make you tear out your drywall to make you re-do the electrical, plumbing, spacing of studs and fire protection. I’ve actually seen cities make doctors tear out all the walls and re-do the process (i.e.: architect, permits, inspections, etc.). Because the city is furious at the doctor for cheating, they will be twice as stringent on their codes and inspections… and take their time approving anything the doctor does. I’ve seen cities take 1 ½ years to approve the remodeling. Imagine the loss of income you’ll suffer by delaying your opening by 1 ½ years, e.g.: $250,000 – $400,000 all because you cheated. Cheaters get caught. Every shortcut breeds new problems.

Anything that can go wrong… will go wrong.

ifitcanitwillgowrongIf there is a possibility of several things going wrong, the one that will cause the most damage will be the first one to go wrong. And, if there is a worst time for something to go wrong, that’s when it will happen. It’s amazing how contractors, subcontractors and suppliers can screw up your plans (e.g.: they will have a $3,000 X-ray tube protecting a 10 cent fuse… the x-ray tube will blow first).

If your X-ray equipment is to be installed on a certain date, it will be late. If it is on time, the floor will be uneven. If it is delivered on time and the floor is even, they will forget the lead for the walls. If it arrives on time and the floor is even and they have the lead for the walls, then the electrician has installed the wrong wiring. Does it sound like I’m being cynical? I’m not. One of my clients purchased her used X-ray machine against my advice. She had it installed and then had a contractor build the walls around it. You guessed it. The machine didn’t work and it couldn’t be fixed or disassembled in order to be removed from the room. Therefore the doctor had to have her contractor tear out the door and the walls to remove the old unit, and then place a new X-ray in the room and then replace the walls. By trying to save a few thousand dollars on a used X-ray machine, it cost her over $20,000 for the contractor to tear out and reconstruct the room. And, she still had to purchase a new X-ray unit.

Lastly, all equipment you purchase will break down after the last payment or when the warranty expires… whichever comes first.

Everything will cost you twice as much as you think it will – then double it.

Trying to save money will usually cost you more money. You’ll find that the few pennies you save will not be worth very much… considering the money you’ll lose trying to save a few pennies.

Unfortunately, the temporary joy of a lower price will soon be replaced by the sorrow of poor quality. I’ve always instructed my Practice Starters® Program clients on the brands of equipment they should buy… or should not buy. Naturally some of my clients didn’t like my advice and bought equipment that was of inferior quality, or had a history of breaking down. I remember being berated by a doctor because I told him not to buy a certain brand of adjusting table… he bought three. After a few years, I asked him how his tables were working. He got red in the face and said all three of his tables had broken down… and the company had gone out of business.

Lastly, no matter how good of a deal you get on your equipment, it will be put on sale later. Count on it.

Did you encounter a different Murphy’s Law when starting your practice? If so, I’d like to hear about it. Send it my way at [email protected] . I’ll see that it gets published along with your name. For more information on starting a new practice go to

Dr. Peter G. Fernandez is the world’s leading authority on starting a practice. He has 30 years’ experience in starting new practices, has written four books and over 100 articles on the subject, and has consulted in the opening of over 3,000 new practices. Please contact Dr. Fernandez at 10733 57th Avenue North, Seminole, Florida, 33772; 1-800-882-4476; [email protected], or visit

Going Paperless in 2012? Great Tips on How to Choose Your New System

ehrgoingpaperless:dropcap_open:T:dropcap_close:o the benefit of chiropractors, there are more and more full automated paperless systems available for their practice. This rapid growth in the chiropractic software industry is due to the high demand of the product, which is great for chiropractors because it keeps prices down.  With all these choices of software systems, how can you make sure you choose the best fit for you and the way you practice?    How can you make sure you choose the provider who will meet the service level you need?  Choosing the right software system and the right provider to suit your needs is very important.  This important choice will reduce your stress and will turn your money into an investment instead of an expense.  Here are a few good tips that will help you to make this important decision.

Online demo

With Internet, it is very easy to shop software systems with online demos.  An online demo can be a good start for your shopping and should be a step during your decision process, but should definitely not be your one and only step.  Software vendors will demonstrate your online demo using small databases, showing you great speed, while in reality, with eight or ten thousand patients in the system, the speed can be very different.  Since a full automated E.H.R. system includes complete patient flow management, it is just impossible to show you that aspect.

Online demos can only show you a few screens here and there but you miss the most important aspect of the system, the patient flow management.  Ask for online demos from a few vendors you are interested in and do not make any decisions at this point.  Don’ t make up your mind yet and stay neutral as much as possible.

Visit a practice close to yours

Ask vendors if you can visit a practice close to yours that uses their system so you can see the system in action.  The software provider will arrange this visit for you.  If they have a good service and a good product, users and doctors are very happy to help their colleagues and show their system.

During  this visit, the users will give you some great tips on how to maximize the system based on their own experience.  By far, this live visit will give you a totally different  perspective of these systems.  Good chances are you will see happy patients coming in, swiping their Chiropractic Health Card in an arrival station, being called and being directed to a treatment room automatically.  The doctor will show you how he sees all X-rays on the screen, how he enters his accurate SOAP notes in the system and so much more.

Try before you buy

At this point, you had an online demo and you visited an office that is using the system.  You saw the system live and you really liked it.  Your decision is made.   But wait!  Seeing it and using it are different, much different.  Maybe your chiropractic technique is different from the doctor you visited.  Your office may be designed differently and your patient flow may also be different.  Don’ t take any chances to lose your money or sign a contract for a system that may disappoint you.  Try before you buy.  Software providers who stand behind their product and service will give you this option.  A minimum of six months to a year of free trial will give you enough time to use the system and make sure it works as expected.  Not only will you try the product, but you will make sure you will be receiving the service and live training you need.  Worst case scenario, if the system does not work as promised or if the service is deficient, you leave and you do not have to spend any money for the software.

This is a very simple and effective plan to shop for a software system.  You can’t miss and you will be assured you will be using the best automated software system for you.  This buying process can be the difference between a nightmare and the greatest investment you have ever made for your practice and for yourself.


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 (  For comments or questions, please email to [email protected]

Building The Sports Chiropractic Practice – A Recipe for Success

:dropcap_open:T:dropcap_close:hroughout my travels I have had the opportunity to meet lots of great people in our profession. Many have been in practice for years, but some are in school, getting ready to graduate or just getting started. I’m often asked by these folks what it takes to build a sports chiropractic practice. The answer essentially revolves around three key ingredients. They are (1) education and training; (2) building strong internal and external relationships; and (3) hard work.   So let’s jump right in and discuss each of these ingredients in detail.

Education and Training 

sportschiropracticWhen I graduated National, I decided I was going to do whatever it took to work for a great sports chiropractor. I was fortunate enough to be hired by Dr. Jan Corwin, who was the official US Olympic Team Chiropractor in Seoul in 1988. I spent a year with Jan learning each day about what a high quality sports chiropractic practice looked like and the importance of having great relationships with people both inside and outside the profession – more on that later. When I decided to return home to my roots in Washington, DC and start my own practice, I realized I had a lot more to learn – clinically. Immediately I enrolled in my CCSP course. In that course, I was trained by some of the world’s best sports chiropractors – Drs. Marianne Gengenbach, Tom Hyde, Bill Moreau and more. Once you begin to go down the road of postgraduate training, my advice would be to never get off. Continuous education to pursue a Diplomate, an ICSSD, a masters in sports, and/or certifications in great programs such as Functional Movement Screen®, Active Release Technique®, Graston Technique®, Kinesiology taping, FAKTR®, and more, can be extremely beneficial. These degrees and certifications are not about the letters after your name – they’re about tools in the toolbox. The more tools you have the more you can correctly apply those tools to the athlete you are treating and their goals and needs. Dr. Tom Hyde, DC, DACBSP, co-founder of Functional and Kinetic Treatment with Rehabilitation, Provocation and Motion (, and one of the world’s preeminent sports chiropractors, emphasizes never stop learning, saying, “It’s amazing how far sports chiropractic has come in the last two decades. Dedication to learning has turned into a process whereby now we are teaching some of the most advanced techniques in managing the athletic chiropractic patient.  Continuous focus on education and evidence-based practice will propel the sports chiropractor to new levels in the future.” Further attending interdisciplinary conferences can be extremely beneficial. Dr. Angela Salcedo, Past President of the International Sports Chiropractic Association and now a member of Federation of International Chiropractic Sport, states, “Attending other sports medicine conferences outside of chiropractic has afforded me the opportunity to build multi-disciplinary relationships. Over the years, these relationships in turn have given me additional opportunities to build my sports chiropractic practice as the team sports chiropractor for the British Virgin Islands Olympic Committee and Track and Field team and support my leadership role in the International Sports Chiropractic Association and the Federation of International Chiropractic Sport.”

Thus, investment and commitment to education and training will pay off in spades when it comes to… 

Building Strong Internal and External Relationships 

This second ingredient is not necessarily a “second step”. Building strong relationships can happen congruently as you build your sports chiropractic skill set. I always recommend that any doctor wanting to be a great sports chiropractor join the American Chiropractic Association Council on Sports Injuries and Physical Fitness (ACASC).  Dr. Corwin took me to my first ACASC convention in Santa Barbara, California. Dr. Corwin emphasizes the importance of intra-professional meetings… “Having a network of other DCs around the country to share your trials and tribulations with, knowing they are also involved in sports chiropractic can be extremely beneficial because the knowledge sharing is so strong.” Certainly for my first ACASC convention, it became abundantly clear that not only was I surrounded by phenomenal sports chiropractors, I was surrounded by phenomenal people. Every person I met was (and still is) completely engaged and committed to bringing chiropractic to the forefront of sports. Not only that, they were, and still are, committed to helping others grow sports chiropractic. I met Dr. Hyde for the first time at this convention and he literally changed my life.  He took me under his wing and helped me, and continues to help me to this day, increase my involvement in sports chiropractic. The lesson to be learned here is that had I never gone to our national association’s convention, I would have never met these people who have had such an impact on my life. And, as great as the professional opportunities that came about because of building these internal-to-chiropractic relationships, it’s actually the personal connections that I’ve made with these great folks that are the most rewarding. In addition, being part of the national association provides tremendous resources to the budding sports chiropractor. Local, regional and national events that require staffing, educational meetings and vendor resources are just a few of the many reasons to join.

The message that was reiterated over and over again in speaking with the world’s best sports chiropractors was that in order to be successful as a sports chiropractor, you had to be humble. Even though we leave school with a passion to literally change the world with our hands, we have to be respectful of the other healthcare providers on the healthcare team. I remember hearing stories of Dr. Phil Santiago, who was the official chiropractor for the 1992 US Olympic team in Barcelona, Spain, cleaning up the training room because there were no patients that day and he wanted to do something to begin to make a contribution. Those sports chiropractors who think cleaning, or helping in any way, is below them will find the road to gaining acceptance long and hard. Those sports chiropractors who are willing to roll up their sleeves and do whatever it takes to make a positive contribution, listen and respect others, and clearly communicate how they can be an integral part of the healthcare team in a manner that is humble, but confident, will excel. Dr. Alan Sokoloff, Chiropractor for the Baltimore Ravens, adds, “Most chiropractors do well to get involved with sports teams, but many of their struggles come with staying involved.  I have found good communication to be the key.  1. Communication with your team supervisor (Physician, athletic trainer, etc.) about what you recommend for the player. 2. Communication with the player and making sure your message is consistent with that of the rest of the medical staff.  3. Communication with your office and family, so they know your time commitments. The goal is to not just get involved, it’s to stay involved.”

What’s the best way to go about building these relationships? If you are already in practice, have inquisitive conversations with your existing patients about themselves, their kids, their friends and family that are participating in sports and offer your services – in your office, on the field, and/or in the company lunchroom for a lecture.  Do they know coaches and athletic directors? Do they know of community groups that are bound by a particular sport – running, skiing, bowling??? For those of you who are starting a brand new sports chiropractic practice and don’t have a patient base to leverage, use my favorite tool…Google…think about the sports you want to serve, and Google “youth football league, your town” and see what comes up. Also spend some time out of the office introducing yourself to local coaches, trainers and owners of health clubs. Dr. Peter Garbutt, President of Sports Chiropractic Australia, states, “I would say that one of the things that I found most beneficial with building relationships with other professionals was to join a sports medicine association and participate in the interests of the organization, not yourself and not chiropractic. Throughout our training and general socialization we tend to become a part of the chiropractic community automatically. We don’t have that luxury within the sports medicine community, so we have to show that we are a part of that community and not an opportunist or pariah in their organization.”

There are infinite possibilities…Of course, if you’re going to be a great sports chiropractor and you’re going to have all these potential opportunities, you better get used to…

Hard work

We’re all tasked with working hard to have successful practices. But the great sports chiropractors take hard work to another level. Working in their practices during the week and then working on the weekends doing community sports events, treating patients on the sidelines or on the court, providing sports injury treatment and prevention lectures, are all critical elements to building your brand as a top sports chiropractor. It takes hard work to raise your level of education, it takes hard work to spend time building new relationships with the outside sports world – coaches, athletic trainers, parents, personal trainers, other physicians.

Most highly successful sports chiropractors work a lot more hours, and they do it not because it’s going to get them another new patient, but for the love of service. They know they can help that athlete recover from an injury faster, prevent an injury and/or provide information and feedback that will change the game in the positive direction for the athlete. It’s that commitment to service that shines through, and when intent is altruistic, great things happen.


Dr. Greenstein is the CEO of the Sport and Spine Companies, a multi-location, multi-disciplinary, evidenced-based practice in the Washington DC Metro region. He is also the President and Founder of the Sport and Spine Rehab Clinical Research Foundation, a non-profit dedicated to high quality, clinical research. He is a member of the scientific advisory board for Thera-band®. He serves on the CCGPP as the Vice Chair and represents CCGPP on the Chiropractic Summit and the Government Relations Committee.

How to Control Your Appointment Book

:dropcap_open:O:dropcap_close:ne subject that tends to get overlooked when it comes to the overall management of a chiropractic practice is simple appointment book control. A lot of doctors haven’t learned that there needs to be a certain rhyme and reason to every minute that is controlled by the appointment book for the practice. Because really, when it boils down to it, there’s only so much time in a day. If that time is not managed properly then it’s going to lead to frustration, distress, and ultimately, failure.
appointmentbookDon’t allow patients to come and go as they please. Schedule them. When you allow the patients to control your schedule, you’ll have a day like this: You’ve got four regular people that show up for their regular care, and then a new patient shows up and waits for an hour and a half to be processed because you weren’t expecting two of the four regular patients, and both the new patient, the regular patients, and the doctor just end up being stressed and frustrated. It just leads to a big break down in efficiency and stress that doesn’t need to occur.
One way to fix that would be something as simple as cluster booking. Cluster booking is essentially blocking time throughout the day where the CA, the chiropractic assistant, and/or the staff know they can’t book any new patients. That two and a half hours or hour and a half or whatever it may be is only to see patient visits for regular care.
Then there will be blocks of time where you’re only going to see report of findings. So if you need to fit in your report of findings, it helps you get into a groove. Also, you’re not bouncing around. You’re able to focus on the patients at hand. It really helps with the efficiency and the effectiveness of what you’re trying to communicate to the patients.
Here’s another point that’s often overlooked. This helps reduce missed appointments. If someone calls and cancels, are they rescheduled for the appointment that was missed? In other words, if they were on some type of care plan where they were scheduled to be seen three times that week but they call on Monday and cancel do you just say, “Okay, we’ll see you on Wednesday.” If so, you’ve just missed that appointment that was originally scheduled in the care plan. So that’s not a rescheduled, that’s just a missed appointment.
A lot of doctors think, well, I had 25 visits scheduled today and 24 of them showed, so we did pretty good. Well, if that was the case, in most chiropractic offices that’s not too bad. However, if they have 25 scheduled, had four missed appointments, and had five drop-ins there is a good indication that there is a problem with appointment book control.
Just on the missed appointments, forget the drop-ins for a moment, just on the missed appointments alone, do you know that if you have one missed appointment a day and you do that for a year’s time that’s over $10,000 you’ve lost? So when the appointment book is mismanaged, and even down to one missed appointment a day, that’s going to lead to dramatic loss of profits and productivity.

When I ask doctors how many additional patient visits they would like to be able to see in a day, effectively and efficiently, with low stress, most doctors will say somewhere around 20 more patients a day.
However, if it takes you 20 minutes to see a patient visit, 30 minutes to do a report of findings, a full hour to process a new patient, then you’re taking up the time in that day that you could be seeing additional patients. There is only so much time in a day, and if you keep running your practice in an inefficient manner, how are you ever going to squeeze 20 more people into your schedule?
Until you can better manage your schedule, the day that you’re going to squeeze 20 more people in is never going to come. Because that’s a stress point. And you cannot outgrow a stress point. It can’t be done until you address it. All of those inefficiencies lead to a “friendship practice” that so many doctors have. Friendship practices are those that allow the patients to come and go when they what to. Patients dictate the care, not the doctor. There’s no respect.
Until you learn to manage the business that you already have, you’re going to be constantly looking for new business. Think about that for a second. If we’re losing business, the very business that we’ve already spent a certain amount of money and time to get into our office, if we mismanage that, then we’re going to be seeking out new business before we really need it. Pay attention to the appointment book and determine to become more effective and efficient in your practice.

by Tom Owen III, and Todd Osborne, D.C.


What Do Insurance Companies Really Want From Me?

:dropcap_open:D:dropcap_close:o you ever sit at your desk, look around at the stacks of requests, letters, and charts and ask yourself, “What do insurance companies really want from me, anyway?”  The volume of new regulations and rules are raining down at a fast and furious pace, and may feel like an out of control, runaway train.  We just master one new policy and they change the rules.  Keeping up with the modifications can make our heads spin, but it is vitally important to stay on top of everything. Usually, staying connected to your State and National Association, a trusted advisor, or consultant can keep you in the loop and up-to-date on regulatory changes. But what about the day-to-day inner workings of your practice?  With all that you manage, what are the handful of most important things to keep track of to steer your practice out of the danger zone, and operating on all cylinders?  Make sure that among all the stacks, rules, regulations, and forms to fill out, you master these five basics to keep your show on the road to success.
Understand Their Definition of Medical Necessity
There is a clear difference between most chiropractors’ definitions of what is clinically appropriate and what a carrier may define as medically necessary. When you are a third party to the relationship between your patient and their contracted insurance carrier, it’s important that you follow their rules. If you happen to be a contracted provider in their network, then you have your own rules to follow as well.  It’s my opinion that if you try to find out medical necessity definitions from the carriers you deal with, you will be well on your way to better documentation and an unmistakable showing of an effort toward compliance. 
Remember that medically necessary care is that which the carrier can justify as payable through the insurance. It is usually tied to certain diagnosis codes and based on medical review policy. They will not dictate what you recommend to a patient as needed treatment, but will dictate that portion which they will pay for. You can treat as you wish, but be sure you only submit for reimbursement that segment that your documentation shows will align with the medical review policy for that diagnosis. The remainder is the part the carrier expects the patient to pay. And the doctor is the link between the two. It’s based on your interpretation of the review policy, and your documentation of medical necessity is the lynchpin. 
Medical review policy is usually found on a carrier’s website, in the physician area, sometimes requiring a password. You can search using their search tools, or navigate to the appropriate section and use key words such as “chiropractic” or a specific CPT code like 98940. For example, many carriers will pay for orthotics. They will tell you upon verification that they are a covered service. But if you failed to read the medical review policy for orthotics, you may have missed the fact that orthotics are only covered if the diagnosis is “Diabetes”.  If you didn’t know that, you may be frustrated when your bill is denied for your diagnosis of “Plantar Fasciitis”.  
Be Proactive with Compliance
In 2000, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) encouraged the voluntary implementation of compliance programs in healthcare offices, particularly those that served the Medicare or Medicaid beneficiaries. In March 2010, as part of the Patient Protection and Affordable Care Act (PPACA), also known as “ObamaCare”, these compliance programs were made mandatory. While there has been no specific deadline by when they must be implemented, it’s likely going to be very soon. The majority of chiropractic offices do not have a compliance program in place. Those that do likely have a program that they bought years ago, thinking it made them compliant, and it has an inch of dust on it from sitting on the shelf. 
:dropcap_open:But if you failed to read the medical review policy for orthotics, you may have missed the fact that orthotics are only covered if the diagnosis is “Diabetes”.:quoteleft_close: 
Think of a compliance program as a self-policing program, where you proactively state that “this is how we do it here” and then keep to it. A Code of Conduct for your office sets the tone of compliance for your team as well. It involves voluntarily auditing yourself for coding, documentation and billing errors, and reporting them and paying back overpayments if necessary.  When these standards are stated, implemented, and managed, a third party looking in from the outside can see that you are not part of the problem, but part of the solution. A well organized office with a compliance program is less prone to simple mistakes.  And if they make errors, they catch them early, and deal with the fall out quickly. An office writing in to a carrier with an overpayment caught by the self-auditing process will be set apart as a stunning example of the way it should be. And you can imagine that if an error was found on a carrier’s audit, the fact that you routinely self-police is a strong, mitigating factor in your favor, trumpeting that you are not doing something fraudulent, which implies intent. 
A doctor I work with called recently with what they thought was the end of practice as they knew it….a team member had been falsifying billing for quite some time, and then stealing the extra money that came in. The numbers were staggering once we started digging and auditing. The amount that would need to be repaid was more than they could fathom. Some of it was from Medicare, which layered on another series of deadlines and regulations. But trust me when I say that this doctor coming forward to the several carriers involved, showing that “we found this as we audited” was a huge mitigating factor in their favor when the carrier began extending payment plans and other considerations. Just think of what would have happened if a carrier began an audit for another reason and found it before the doctor did. Setting up a compliance program is a simple process with an uncomplicated structure. Don’t be caught without one. 
Code and Bill Correctly
If you have a compliance program in place, then you probably will do your coding and billing appropriately.  The CPT and ICD numbers reported on your patient’s billing is the language used to communicate your services to the third party payer. Simple auditing techniques will make sure that errors are minimized. But, if you use codes that are not a clear and obvious description of the work you’re doing, you could run into trouble. Make sure that you clearly understand the parameters for the use of every code you bill. Some codes require particular modifiers, and others require certain pieces of documentation to be present in your notes for use of the code. When you report a code, and it’s paid, don’t assume that because they paid it all is well. Usually, errors are found on post payment audit, and “I didn’t know” is not an excuse that will hold water. Repayments of erroneously billed codes still have to be refunded. The great news is that coding and billing correctly in chiropractic is pretty easy.  Diagnosis codes are straightforward, and there are a small handful of CPT codes that apply to our services. Even with the implementation of ICD-10 in 2013, it’s an area of your practice that must be exactly correct. You can’t afford to take the risk of erroneous coding and billing. It will cost you time and money when you may have precious little of both.
Be Aware of Documentation Requirements
Federal and state reports on the audit of chiropractic documentation indicate that chiropractors don’t have a good handle on proper case management and documentation requirements. Some jump to purchase EMR software thinking it will solve all documentation problems, but end up with an unhappy experience. You must learn the requirements on your own and master the documentation of your care.  The best way to do this if you find your documentation lacking is to use a good paperwork system that will prompt you along the way with appropriate requirements so you don’t miss a thing. It’s a great bridge from the travel card you may be using now to EMR software that may be required in the future. Using appropriate forms will guide you and teach you the nuances of documentation that you must learn. The Medicare documentation requirements are easily found in your Medicare carrier’s Local Coverage Document (LCD). Read it! And implement those requirements. 
Don’t Charge the Carrier Significantly More Than You Charge Your Patient
Offices that routinely offer cash discounts to patients under the guise of “time of service” pricing are usually in violation of a myriad of inducement and compliance rules. It usually goes like this:  An insured patient’s carrier gets a bill for a manipulation, traction, and exercise at the doctor’s actual fee schedule, which comes to $120.  Meanwhile, a patient who has no insurance comes in and is quoted the “time of service” fee of $40.  Can you see why a carrier may have a beef with being “overcharged”? It’s a violation pure and simple, unless you’re following the OIG’s guidance of no more than a 5-15% prompt payment discount. Would an average of $12 savings (10% of the $120 actual fee) really help that cash patient? This is why most doctors are discounting far more than the allowed 5-15%. The easiest fix is to join a reputable Discount Medical Plan Organization (DMPO) like ChiroHealthUSA. This allows you to set a network fee schedule for your cash paying patients too, and this keeps insurers from feeling like you’re gouging just because someone has third party coverage. 
Focus on these five areas should strengthen your relationships with the third party payers you deal with. It’s important to keep them healthy and strong, so you can continue helping your patients be the best they can be, without worries of third party payer interference.  It’s possible! And it starts with you!

Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and, since 1983, has been providing chiropractors with hands-on training, advice and tools to improve the financial performance of their practices. A well-known and sought-after speaker, Kathy has served in national and state level chiropractic organizations, sits on diverse boards and advisory councils related to the profession, and is frequently invited to address chiropractors in important conferences and seminars around the country. In 2007, KMC University was created to streamline, develop and offer a broader range of chiropractic solutions in the areas of coding, insurance, patient financial procedures, Medicare and compliance. She can be reached at 888-659-8777 or [email protected]

The Economy, The Boll Weevil, and Your Unexpected Prosperity


moneystack:dropcap_open:T:dropcap_close:alk to just about anyone, in any profession these days, and a similar theme weaves itself throughout the conversation; our nation’s poor economy has left few untouched. Many chiropractors have certainly felt the sting of this unfortunate downturn. We’ve had numerous conversations with several practicing chiropractors in recent months and no doubt, times are tough out there.  However, we’ve noticed that while many stories started out with the same details– lower collections, few patient visits, a few of these doctors have ended the conversation by saying their practices are healthier than they have been in a long time and their outlook is optimistic for the future. The circumstances started out the same, why were the outcomes different?  It may surprise you to know it had nothing to do with the market, their staff, or a magical newspaper ad. The difference was in the doctor’s response to the adversity he or she faced.

While some doctors lament their falling collections and hopelessly describe their uncertain future, others, in the same circumstances, tell us a different story. They say when their practice started hitting bottom; they knew they had to do something different. Let’s take a time-out right here. That sounds simple, doesn’t it? Something isn’t going the way we need it to go, so we decide to do something different. Simple logic. However, we never cease to be amazed at the powerful results of acting on this simple thought, and we also never cease to be amazed at the number of doctors who don’t think this way.

We tell clients who find themselves in troubling situations that if they don’t do anything about their current situation, they’re insane. That may sound cruel until you understand our definition of insanity, which is, “continuing to do the same thing while expecting different results.”

If something isn’t going right, it may be time to do something different. This is the blessing of adversity. Adversity forces us to acknowledge that our current way of doing things isn’t working. It forces us to consider change and do things we may have otherwise never done. This was the common thread in the different outcomes of stories we’ve heard from doctors all over the country. Some of them do nothing, and watch their practices shrivel up and die, while the adversity our economy has brought has stirred others out of their comfort zones and forced them to make changes within their practices. Those changes, albeit uncomfortable or risky, brought about the success they needed to survive the perils of the economic downturn. For many of them, the change they made was calling us and asking for our help. Most admit, they would have never sought out our help had it not been for the desperation they felt as a result of this horrid economy.  The adversity they encountered was a blessing in disguise because of their proactive response.

The current situations of many chiropractors remind us of a true store that happened over a century ago in Enterprise, Alabama. This small town’s commerce was all but wiped out, but the same culprit that almost destroyed it, is now the town’s hero. What is on the monument that now stands at the center of Enterprise, Alabama’s town square? A boll weevil.

The monument honoring the boll weevil is a robed, Statue of Liberty look-alike, holding the enormous black bug over its head. The statue’s head is bowed in somber respect.

The boll weevil ravaged 60 percent of the region’s cotton crop in 1915, and even more the next year, decimating livelihoods and towns. Yet, the inscription on the monument’s base says, “In Profound Appreciation of the Boll Weevil and What It Has Done as the Herald of Prosperity.” The herald of prosperity? The boll weevil?

In 1917, with their economy and society almost destroyed, the down-and-out farmers of South Alabama faced tremendous adversity, much like many in our profession are facing today. However, the adversity the boll weevil caused, forced these farmers to do something different. They had no choice; they couldn’t grow cotton any longer. They were either going to die into extinction or they were going to have to adjust and innovate. Over the next few years, they began diversifying into peanuts and other crops and no longer depended so heavily on cotton. This forced change helped the farmers of Enterprise thrive, even when other areas of the South, primarily dependent on cotton, continued to suffer. Take note, the other areas of the South didn’t suffer under the destruction of the boll weevil, their adversity wasn’t as severe, therefore, they were not forced to make the needed changes and diversify their crops. For the farmers of Enterprise, the enormity and severity of their adversity, and their response to it, saved their economy and birthed their prosperity.

What changes is your adversity forcing you to make? Consider the cotton farmers of Enterprise, Alabama and consider making those changes to save your future. What you are suffering through right now may be just what you need to propel you into the changes that will bring the prosperity you’ve been waiting for.


by Tom Owen III, and Todd Osborne, D.C.

Dr. Todd Osborne, a 1989 graduate of Palmer College, ran a successful high volume multiple doctor practice, and is currently Vice President of AMC, Inc., as well as an author and lecturer. Visit or call (877) AMC-7117 for more information.

Finding a Great Associateship


associateshipthatworks:dropcap_open:I:dropcap_close:n my previous articles, I described the types of associateships that are, and are not, successful.  Now that you know the type of associateship you should look for—here’s how to find that “needle-in-a-haystack associateship from Heaven.”

A potential associate should search for an established doctor who is earning $500,000 or more per year.  Do not associate with a doctor practicing below this level, as one of your associateship goals should be to learn how to run a large, successful practice.  You can only learn this by either hiring an experienced consultant, or by associating with a doctor who is already doing it.  The established doctor must also be able to comfortably give the associate doctor 20 to 25 new patients a month, without a financial worry if any are lost. Only a very successful doctor with a large volume of new patients can match these criteria.  Don’t settle for less when you’re looking for a great associate position.

Looking for a Successful Associate Doctor Practice

Your first step is to talk to the president of the county chiropractic society of the area in which you’re interested.  Ask him who the area’s most successful and ethical practitioners are that hire associates. Your association president will know. Then, speak with those doctors and ask if they need an associate. If they do, apply for the position. If not, ask them who the most successful practitioners are in the state who operate good associate practices. They’ll know. When you ask three or four doctors the same question, you’ll find the same names cropping up.

Go to these doctors and ask them for a job. If they don’t have a position available, ask them to refer you to other super-successful, ethical doctors who are good trainers of associates. If you appear to be good associate material, they’ll be happy to do so.

By following these steps, you will find the super-successful associate practices. The doctors who run these practices are networked by mutual interests and concerns, and are openly supportive of each other.

Your next step is to contact the practice consultants that have clients in the area you are interested in practicing.  Ask them about large successful associate practices.  They’ll know and will be happy to guide you to a successful practitioner.  If the successful practitioner has a full complement of associates and is not hiring at the time, ask him for a referral to other successful associate practices.  He’ll be happy to help you.

Another method of finding a successful practitioner is to ask vitamin and chiropractic equipment vendors in your state.  These people know everyone.  They will be happy to steer you in the right direction because the more successful they make the established doctor by referring a good associate (YOU) to them, the more vitamins, orthopedic supplies, or equipment they will sell the established doctor and, thereby, the more successful the vendor will become.  Everybody wins.

Look for “Associate Wanted” ads in the classified ad section of the local chiropractic society newsletter, your state association journal, and our national journals.  Call these doctors and follow the previously described recommendations.

Another fruitful source of associate positions is through the profession’s employment agencies, vacation doctor companies, etc.

Finally, if the previous methods of finding an associate position are not successful, write a letter to all the practicing DC’s in the area of the state in which you’d like to practice.  In this letter, state you are looking for an associate position, your qualifications and your willingness to work hard.  You’ll be pleasantly surprised by the response.

Best of luck in finding a great associateship.  I did and it was one of the most rewarding experiences of my life. I had the best teacher and, because of the training he generously provided me with, I became a success. Forty years later, I still follow the principles and guidelines he taught me. I’ve had a dozen associates, who I trained the same way and I’m extremely proud of their subsequent successes.

Doctors, I hope you follow the guidelines of this article. Identify and avoid the types of associateships that will only trap and hurt you. Find a good associate position…become a great associate!  When you become a great associate, you’ll become a great doctor. And, when you learn what the successful practitioner knows, you’ll be able to duplicate the established doctor’s success after you have successfully opened your own practice.

More information on becoming an associate and the specific responsibilities of the established and associate doctors in an associate and independent contractor practice is available online at

When you’re through being an associate and are ready to start your own practice, hire a consultant who specializes in starting practices to guide you.  Don’t think that you now have the experience necessary to start and build a new practice…you don’t!  Yes, you’ve gained the experience of caring for patients and learned some good office procedures, but that’s not enough knowledge to start a successful new practice.  You still have to learn how to find a great office location, effective bank negotiating strategies, cost-cutting remodeling negotiations, how to market a new practice, etc.  It’s the lack of this specialized knowledge that dooms new practices, not the lack of knowledge regarding patient care.


Dr. Peter G. Fernandez is the world’s authority on starting a practice.  He has 30 years’ experience in starting new practices, has written four books and numerous articles on the subject, and has consulted in the opening of over 3,000 new practices.  Please contact Dr. Fernandez at 10733 57th Avenue North, Seminole, Florida, 33772; 1-800-882-4476; [email protected] or visit

Chiropractors as Entrepreneurs

entrepreneurchiroWhen confronted with the full weight of running a practice, a chiropractor’s reaction is often:

  • Why didn’t they teach this to me in chiropractic school?
  • Can I hire someone else to run my practice for me?
  • Isn’t it possible to just practice chiropractic and not worry about the business?

After reading the book, The E-Myth, by Michael Gerber, we couldn’t help but marvel at its applicability to chiropractors. Many in our profession often feel overwhelmed with the business side of their practice because they run it with the “entrepreneurial myth” or “E-Myth” that says, “If you understand the technical work of a business, you understand a business that does that technical work.”

It’s okay to love the technical part of chiropractic, but the aforementioned thinking confines you to running your practice as a technician.  This leads to frustration, because you need more than a technician’s skills to run a practice successfully.  The answer to this conundrum is to discover the possibilities open to you, not only as a technician, but also as an entrepreneur.

The truth is that for any practice to be successful, the chiropractor/owner must be able to blend and balance not one, but two roles effectively.  It’s not just about being the good “technician” and giving quality adjustments.  It’s also about being an aspiring entrepreneur.

What is an entrepreneur? According to Michael Gerber, “It is the dreamer in us, who sees a vision different from the present and is the catalyst for change.”  Entrepreneurs would run a practice by implementing new systems, skills, technologies, and setting goals.  Entrepreneurs dream about where they want that practice to be in the future and meet those goals by thinking outside the box and being creative.

The technician is the doer and loves to do the work. His or her focus is not dreaming about things, but doing them.  As long as the technician is working, he or she is happy. Therefore, the technician lives in the present. The entrepreneur plans and directs the future of the practice by setting goals and creatively meeting those goals.

In order to grow a practice, chiropractors need to shift their focus from working in the business to working on the business.

Most likely, you are already a good technician.  You know how to adjust. You get good results with your patients. You learned all of that in chiropractic college.  But what about the entrepreneur in you? Have you allowed that part of you to come into focus?

The entrepreneur is the inventor, goal setter, visionary, and dreamer within us. Begin by dreaming and creating new and better ways of providing chiropractic services, caring for patients, and reaching new successes.  Allow yourself to be more than “just” a chiropractor, understand that you are an entrepreneur, and be mindful of these two factors:  momentum and stagnation.

Have you ever known, early in a particular month, that it was going to be a bad one, with frustration, inefficiency, low production, and high stress? It seems the practice in general is moving in the wrong direction, but the momentum seems so overwhelming that you simply cannot apply the brakes? In times like that, imagine how you would react if someone said, “Wait a minute. Take a step back. Think about new ways to schedule, so that the month doesn’t have to be bad.” It would be easy to respond, “Leave me alone. I’m too busy doing what I’m doing to think about how to do it better!” If this sounds familiar, you’ve been taken by the force of momentum, the unhappy state of speeding in the wrong direction, yet feeling unable to stop yourself. Momentum challenges us all, but, by recognizing it and redirecting the momentum, you can take on a new direction in which to steer your life and practice.

Someone who has been taught to view creativity as risky simply stops being creative. Don’t let this happen to you. Invest in new skills, goals, and visions for your practice. Invest in yourself. When stagnation gets in the way, it becomes more comfortable to cling to the status quo. Are you caught in the rut of being unhappy with your practice, doing the same thing while wanting different results?  How many times do we hear chiropractors complain about an insurance issue or a staff problem—only to learn that they have been plagued by the same problem for years and have never taken steps to resolve it and move on. Stagnation prevents you from taking risks; it stops you from finding new pathways.

If you have been in practice for many years and have accepted the routine, the safe, and the comfortable, there will come a time when you will feel unfulfilled and uninspired. You will wake up one morning to find that you have lost your passion. Focusing on the entrepreneurial spirit in you means creating and pursuing new possibilities that you really want to achieve. Allow yourself to dream about your future, whether you’ve been in practice two months or twenty years.  Once you are ready to enter the world of the entrepreneur, you can begin to build the kind of practice you would really like to have.


by Tom Owen III, and Todd Osborne, D.C.


Dr. Todd Osborne, a 1989 graduate of Palmer College, ran a successful high volume multiple doctor practice, and is currently Vice President of AMC, Inc., as well as an author and lecturer. Visit or call (877) AMC-7117 for more information.