Category: Practice Management

Thoughts on Sailing and Chiropractic

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

Sometimes there are situations in our lives that desorient us

 

My father, Dr. Thomas Owen, has often made the statement, “Every principle in business and in life can be related to flying an airplane or sailing a boat.”  Growing up we spent a large amount of time sailing in the Gulf and there certainly are many parallels between life at sea and life as an entrepreneur. One trip in particular comes to mind as a perfect example.
On the day we planned to set sail we were greeted with storms and high winds left over from a hurricane in the Gulf.  Our first priority was getting safely out of the harbor, and we quickly realized that task was going to require careful forethought and planning. We checked the forecast and then took into consideration such factors as the location of our slip in the harbor and the lack of visibility and state of the waters caused by the weather. We combined that information with our past experiences on the sea to determine how to safely get out of the harbor and set sail. We didn’t have a 100% guarantee of the weather or for our safety and success on the sea that day, but we took what we did know and used it to formulate a plan.

Continue reading “Thoughts on Sailing and Chiropractic”

7 Secrets on How to Stay Purpose-driven & Profitable in Any Market

 

In my 25 years as a chiropractor, business consultant to chiropractors, and CEO of Chiropractic Leadership Alliance (CLA), I have seen many challenges dealt to the field of chiropractic. Through it all, my job has been to help DCs face these challenges and thrive.

Continue reading “Making Purpose Profitable”

 

*Note:  Thomas A Owen III has recently written a book, co-authored by Dr. Todd Osborne, entitled, “Chiropractic From a Businessman’s Perspective”. Following is an excerpt from the book:
Many doctors tell us that when they think of efficiency as it relates to their office, they think of paper work or something that involves tasks performed at the front desk by their chiropractic assistant. It may surprise you to know, that efficiency has as much to do with the floor plan in your clinic as it does with the paper work at the front desk.

Continue reading “Excerpt from the book: Chiropractic From a Businessman’s Perspective”

During a recent after-dinner trip to a favorite ice cream eatery, I happened into the Ladies’ Room. Hanging next to the sink was a detailed, with pictures, explanation of how to wash your hands. Honestly, do any of us really need a primer on how to wash our hands? Of course not! But this national chain ice cream eatery was practicing what most of corporate America knows is vital to running a business…Standard Operating Procedure (SOP). If they wanted their employees to properly wash their hands, they were going to spell it out, step by step.

Continue reading “What’s SOP Doc??”

In the last issue, I discussed the reasons behind the increased audits and reviews and the decreased fees. This issue, I will explain more about the recovery audit contractors and why they will be a problem for the foreseeable future.

 

In March of 2005, CMS started the Recovery Audit Contractor Demonstration Project. The project originally included three states (New York, Florida and California) with one contractor each. In December of 2006, Congress mandated that the Recovery Audit Contractor program be made permanent. In June of 2007, Massachusetts, South Carolina and Arizona were added to the states covered by the demonstration project. During the demonstration project, the three RAC’s recovered $992.7 million while earning $187.2 million in contingency fees (commissions). Continue reading “The Recovery Audit Contractor and What It Means to You”

Mrs. Jones enters your office complaining of leg pain or arm pain and you perform a clinical examination which reveals a radicular component, or worse, a myelopathic component. At the end of the examination, you order and take X-rays and, upon your clinical conclusion, do a diagnostic work-up, as you aren’t sure of the etiology of the neurological involvement.

You have 3 avenues for communication with your patient:

• Choice #1: You tell the patient that you are going to embark on a conservative course of care, with gentle adjustments and, at the end of 6-8 weeks, should the problem persist, you will consider an MRI.

• Choice #2: You tell your patient that you aren’t really sure of what’s going on; however, you want to embark on a course of delivering high velocity thrusts into his/her spine. If you’ve guessed right, he/she will be just fine. If you’ve guessed wrong, then there is a chance that you can hurt him/her badly, possibly causing permanent neurological problems that will necessitate surgery or worse…. But, not to worry, because you are a really good guesser…. So let’s get going!!!!!!

• Choice #3: You tell the patient that you really aren’t sure of what’s going on; so, before you proceed with care, you are ordering an immediate MRI to get an accurate diagnosis, create an accurate prognosis and then design the treatment plan.

What is the difference between scenarios #1 and #2? Nothing, as they both say the same thing and #1 is eloquent nonsense while, in scenario #2, the sobering truth is told. In speaking across the country to doctors and members of chiropractic state boards, the consensus of the rule is consistent: IF YOU DO NOT KNOW, YOU DO NOT TOUCH.

Somewhere along the way, the insurance companies hired some slick lawyers to go to court and argue that MRI’s shouldn’t be paid for if there isn’t 6-8 weeks of conservative care prior to the MRI being performed and the only time an MRI should be considered prior to the 6-8 week waiting period is if it is urgent. Then it exclusively is performed in an emergency room. When that reimbursement ruling first came down 10+ years ago in New York, I contacted both the Secretary for Chiropractic and the Secretary for Medicine (for confirmation) in the New York State Department of Education; the answer was clear and is consistent nationally. “If you think there is a neurological problem of the root or cord and there remains a diagnostic dilemma as to etiology, you are bound to use every means available to conclusively diagnose your patient. That includes an MRI, regardless of the pressure of the insurance companies.” They went on to further state, “If you do not do the MRI and your patient gets hurt because of underlying pathology, you stand a good chance of losing your license.”

Do not lose sight of the fact that denying MRI’s is a big business for insurance companies and you are often a willing accomplice to their business plan at both your own peril and that of your patients. We do not answer to the insurance companies or the courts. Our covenant is with our state licensure boards that are charged with protecting the people of our state. You are bound to follow those standards.

I have had a simple rule for decades; if there is a radiculopathic or myelopathic involvement, I will always order an MRI prior to adjusting the patient. These are as a result of a space occupying lesion and I need to be certain of what that lesion is. You do too. If I don’t know, I don’t touch.

Radiculopathy is not a specific condition, but rather a description of a problem in which one or more nerves are affected and do not work properly (a neuropathy). The emphasis is on the nerve root (Radix=”root”). This can result in pain (radicular pain), weakness, numbness, or difficulty controlling specific muscles.

In a radiculopathy, the problem is at or near the root of the nerve, along the spine. However, the pain or other symptoms may manifest in an extremity through a process called referred pain. For example, a nerve root impingement in the neck can produce pain and weakness in the forearm. Likewise, an impingement in the lower back or lumbar-sacral spine can be manifested with symptoms in the foot.¹

Myelopathy refers to pathology of the spinal cord. When due to trauma, it is known as spinal cord injury. When inflammatory, it is known as myelitis.²

In addition, myelopathy is a compression of the spinal cord with ensuing neurological deficit distal to the level of lesion. Aggressive chiropractic care is indicated in almost every instance. However, in that small percentage of patients who fall into the latter category, you will be grateful you ordered MRI’s and practiced with certainty. Your goal is simple; create an accurate diagnosis, prognosis and treatment plan prior to delivering your treatment.

To take it a step further, you must learn to interpret your own MRI’s, as general radiologists, having only 6 weeks as a rule in spinal MRI training, have an error rate upwards of 40%. Be in full control of your patients’ care and your practice and win by being the best-of-the-best.

Dr. Mark Studin is a consultant and educator. He teaches how, through clinical excellence, to build PI practices and can be found at www.teachchiros.com. He is also the creator of the US Chiropractic Directory that hosts the world’s first CV builder for chiropractors and offers that for free to doctors of chiropractic and can be found at www.USchirodirectory.com.

References

1. Wikipedia. (n.d). Retrieved from http://en.wikipedia.org/wiki/Radiculopathy.

2. Wikipedia. (nd.). Retrieved from http://en.wikipedia.org/wiki/Myelopathy.

I have heard this question a lot as I consult with chiropractors all over the country. In a discussion with one doctor, he stated that six years ago he had been reviewed with no problems or errors. He was reviewed a few months ago and had a 100% error rate. The puzzling part was that he hadn’t changed his documentation system in that time. The documentation that was 100% OK just six years ago was now 100% wrong. What happened?

Two things happened. One: Medicare has better defined what they expect from chiropractors regarding documentation; and Two: Medicare is required to maintain budget neutrality.

In 2003 and 2004, Medicare made several revisions to Chapter 15, Section 240, of the Benefit Policy Manual. Section 240 details Coverage of Chiropractic Services and includes information about what documentation Medicare expects on initial visits and subsequent visits. With this information in hand, reviewers have been better able to define what Medicare expects from chiropractors regarding their documentation.

Medicare has been mandated by law to maintain budget neutrality. The Centers for Medicare and Medicaid Services use a complex formula to calculate the Physician Fee Schedule. This formula uses a Conversion Factor (CF) expressed as a dollar value and adjusts it using a Work Relative Value Unit, a Practice Expense Relative Value Unit, a Malpractice Relative Value Unit, a Work Geographic Practice Cost Indices, a Practice Expense Geographic Cost Indices and a Malpractice Geographic Practice Cost Indices. Confused? Don’t feel alone.

If it helps, the formula looks like this: [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF.

I don’t know about you, but I’m as confused as ever. What is important to note is that CMS can change any value or combination of values in this formula and cut our fees. “Section 133(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required that the Secretary of the Department of Health and Human Services apply the required budget neutrality (BN) adjustment to the CF (conversion factor) beginning January 1, 2009, instead of continuing to apply the BN adjustment to the work RVUs required as a result of the Five Year Review of Work.” The Medicare Physician Fee Schedule Conversion Factor at the time of the writing of this article is $36.0846.

So, what does this mean to you, the doctor, trying to make a living by helping other people? It means that Medicare is watching you closer than ever. The reality of the situation is that Medicare must provide services to an ever-increasing pool of beneficiaries without spending more money. They will accomplish this by increasing premiums, increasing deductibles, and recovering “overpayments” to doctors and other providers. Medicare’s definition of an overpayment is any payment that has been made to a provider that is not supported by the documentation in the patient’s chart.

Medicare has arrayed a mighty horde of contractors and subcontractors to ensure that no overpayment is missed. Everything from the new Recovery Audit Contractors (who are paid on commission) to the newly re-named Zone Program Integrity Contractors to the reviewer at the local Medicare Administrative Contractor are there to ensure that payments are made only for medically necessary services. If the documentation does not prove that the services were medically necessary, then they weren’t and you owe Medicare some money.

The scope of this article is not to give you all of the details of the various Medicare contractors and how they will review you, but rather to make you aware Medicare has greatly increased their efforts to collect money from you.

Concerning Medicare, what worked ten years ago or even five years ago isn’t good enough today. When you hear the stories about the doctor that had to close his practice and file bankruptcy because of Medicare reviews or the doctor that Medicare is attempting to collect $1.5 million from, believe them. I know for a fact that these stories and countless more like them are true. Your best defense is to update your Medicare protocols and keep them current. Strongly consider implementing an office compliance program. If you don’t know what that involves, then hire a consultant that does. It will be money well spent.

Dr. Ron Short is a certified Medical Compliance Specialist, a certified Peer Review Specialist and a certified Insurance Consultant. He consults with doctors regarding Medicare and office compliance programs as well as presenting seminars on Medicare, documentation and compliance. You can send your question or comments to Dr. Short or join his mailing list at [email protected].

 

Well, the dust has settled and the reports have been published, The Chiropractic Demonstration Project is finally over. So, how did we do? Well, we won and we lost.

The key points of the demonstration project were:

• “Section 651 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

• Centers for Medicare & Medicaid Services (CMS) to conduct demonstration evaluating feasibility and advisability of expanding coverage for scope of services that chiropractors are permitted to provide

• Four sites: 2 urban, 2 rural; one of each must constitute a Health Professional Shortage Area (HPSA)

• Demonstration will operate for two years and must be budget neutral” ⁱ

 The entire profession expected to do well under these conditions. We expected to demonstrate savings to the Medicare program by offsetting the increase in chiropractic payments with decreases in hospitalizations and surgeries.

When the final report came out, we found that we were over budget by a substantial margin. Depending upon which calculation you use, we were either $50 million over budget or $114 million over budget. That requires some explanation. The results of the demonstration project were calculated in two ways: 1) chiropractic only patients and 2) all Neuromuscularskeletal (NMS) diagnoses patients. There were flaws in both methods.

“The All NMS User and Chiropractic User each has strengths and limitations. The former avoids selection efforts by including all beneficiaries who were potential targets for chiropractic services under the demonstration. At the same time, its results are affected significantly by changes in the cost of care for the 86 percent of individuals who did not receive any chiropractic services. The Chiropractic User analysis, on the other hand, directly reflects the impact of expanded coverage for chiropractic services but may miss unintended effects of the demonstration on services provided by other types of health care professionals.” ⁱⁱ

 In other words the Chiropractic User analysis would show an increase because Medicare is paying for more services and the All NMS User analysis would show an increase because only 14 percent are under the care of a chiropractor.

The analysis also included a breakdown of the geographic areas. The demonstration project was conducted in four distinct geographic areas: the entire state of Maine, the entire state of New Mexico, 26 counties in northern Illinois, plus Scott County in Iowa, and 17 counties in central Virginia. The cost analysis by both user groups was broken down into each geographic area.

“The breakdown of All NMS User results by state indicates that Illinois counties accounted for all of both total and per-person increases in costs. Increases in costs in Illinois were offset by significant reductions in Maine, New Mexico, and Virginia. Within Illinois, Chicago and its suburbs accounted for 88% of total increase in costs.” ⁱⁱⁱ

“The positive net impact of the demonstration (i.e., increase in costs) was completely due to the $240 per beneficiary effect of Chicago (t = 13.7, p<.01); while the effect of the other demonstration counties was a negative $31 (t = 2.1, p<.05).” ^iv

In other words, Chicago increased the per-beneficiary cost to Medicare by $240.00 while all of the other demonstration counties realized a savings to Medicare of $31.00 per beneficiary.

The beneficiaries were surveyed and “reported good relief of symptoms and high degrees of satisfaction with the chiropractic care they had received. Nearly 70 percent of the survey respondents indicated that they had insurance, in addition to Medicare, that covered chiropractor services.” ^v

So, overall there is good news and bad news from the Chiropractic Demonstration Report. The bad news is that we were overbudget by a significant amount and Medicare has focused on this one aspect by reducing chiropractic reimbursement by between 2% and 3% starting in 2010.

The good news is that we realized a notable savings to Medicare in 4 of the 5 geographic areas of the demonstration project. The patients reported a high degree of satisfaction with the care that they received from their chiropractors.

To highlight the good and ignore the bad would be to invoke that oft-used metaphor of rearranging the deck chairs on the Titanic. We, as a profession, need to urge those responsible to determine what happened in Chicago to cause such an uncharacteristic increase in costs.

The end result is this: You can pretty much find something in the report to support any position on chiropractic that you wish to take. We will have to watch to see what position CMS takes.

Dr. Ron Short is a certified Medical Compliance Specialist, a certified Peer Review Specialist and a certified Insurance Consultant. He consults with doctors regarding Medicare and office compliance programs as well as presenting seminars on Medicare, documentation and compliance. You can send your question or comments to Dr. Short or join his mailing list at [email protected].

References:

iChiropractic Demonstration Power Point Presentation

iiReport to Congress on the Evaluation of the Demonstration of Coverage of Chiropractic Services Under Medicare, Page 18

iiiReport to Congress on the Evaluation of the Demonstration of Coverage of Chiropractic Services Under Medicare, Page 14

ivAnalysis of the Budget Neutrality of the Demonstration of Coverage of Chiropractic Services under Medicare, Page 10

vReport to Congress on the Evaluation of the Demonstration of Coverage of Chiropractic Services Under Medicare, Page 19