Franchising, Is it for Me?

:dropcap_open:H:dropcap_close:aving been in business for over 40 years and franchising for over a decade, I often get asked why would anyone buy a franchise when they could just open their own business.  They will then go on to tell me about some friend or relative who invested a lot of money in a franchise just to lose it all or have the franchise go out of business.  These are usually people who have no concept of what it takes to start a business and have not done any research on franchises. The facts speak for themselves; when you look at the statistical data provided by FranFinders, franchise consulting group, franchise businesses account for nearly 50% of all retail sales in the U.S. Franchise businesses employ more than 14 million Americans, with an estimated 5,000 franchise concepts in 75 different industry categories.  To be even more concise, 1 out of every 12 businesses in the U.S. is a franchise and total sales for franchise businesses are approximately 2 trillion dollars annually. 
franchising5Even though you may hear reports of franchises closing in the media, the fact is that from 1971–1997, less than 5% of franchise businesses closed each year.  A study conducted by the U.S. chamber of commerce found that 95% of franchises are still in business after 5 years, compared to just 47% of self-launching businesses.  Buying a franchise more than doubles your chances to survive as a business owner, and by choosing the right franchise your likelihood for success can be greatly improved. So how do you choose the right franchise for you? Do you jump on the latest and fastest growing hot trends, or do you go with an older more established company everyone knows and that has a strong brand identity?  Would you rather stay in your comfort zone and do something in a field you are more familiar with?  Do you want a big business, small business, home based, or the chance to have multiple locations? What is the size of the market and how strong is the franchisor? The truth is, the reason most franchisors are successful comes down to just several things. First, the business model has proven to be successful and profitable and has the history and data to prove it is sustainable and not just a fad. Next, the franchisor is always striving to provide its franchisees with the best possible business tools to support them in all areas of the franchise business. 

The strongest franchise companies will take the time and money to reinvest in supporting their franchisees and develop ways to open communication and listen to their community. A good franchisor will make decisions that benefit all its franchisees equally, greatly increasing your chances for success. So back to the question, should you jump on the hot new franchise concept or not? Do so only if you believe and can prove it is sustainable and the franchisor has the support systems in place to help you while building a strong brand.

Sometimes, new franchisors cannot grow or react fast enough to support their rapidly growing network. It takes a great deal of time and a good management team to create, develop and implement new, strong systems and establish a positive brand image all at once. However, if you are one of the first franchises and the brand explodes, the equity and value of your franchise could be huge in the future. Do your research carefully on new franchise concepts and talk to as many existing franchise owners as possible asking for their candid opinion on how the franchisor is handling their growth. More established franchise companies should look and feel like well-oiled machines and provide you the greatest chance for success, but often times it is hard to find good new locations and territories when the brand has been around for a while. Established franchise concepts can also be considerably more expensive because the brand has grown and become more valuable.

Do you want to stay in your comfort zone? If the franchise culture doesn’t mesh with your personality, then your chance of success could be greatly reduced. If it requires a certain skill set like a strong sales background, and you don’t enjoy sales, don’t do it. If you are already trained in or are familiar with the franchise concept you are looking at, all the better. The franchisor will then just need to train you on their systems and culture and give you the tools to market and manage your business. No matter if you wish to have a small, home based franchise or a larger more established franchise, the process is the same. Do your homework; there is a saying in franchising— when you buy a franchise, you are in business for yourself but not by yourself.

Before buying any franchise, a visit to the corporate office for a discovery day to meet all the different departments you should have at your disposal, is a must. Initially, you will incur the cost of a licensing fee which gives you the right to learn the systems, use the name, logos and intellectual properties developed by the franchisor and provide you with extensive training on the model and its systems. On an ongoing basis, you may also be paying a royalty fee back to the company to help support you and your franchise business. Always know what support is available to you and use it. That is what your royalties are for.

:dropcap_open:So if you think you can own a franchise and have control over the offer, message, pricing, look, and logos then franchising is not for you.:quoteleft_close:
With over 5,000 different franchises to choose from, you can take your time. You should never purchase a franchise you’re not certain about and the decision should be yours alone and never left to a salesperson or broker. I truly believe that buying a franchise is a wonderful way for first time business owners to learn many of the basic business skills they can use the rest of their lives. Marketing, accounting, time management, information technology, vendor relations, real estate, the list goes on. For those who are more experienced, many franchise companies have area or regional developers who represent and support a group of franchisees in a certain geographical area. Regional developers are franchisees who buy the right to sell, develop and oversee a defined geographic area and must be well-trained on the model and operating systems. They not only represent the franchisor’s interest, but also the franchisee’s.

I believe that franchising definitely gives you the greatest chance for success, but I also know that franchising isn’t for everyone. Franchisors must protect their brand identity, story and image at all costs. So if you think you can own a franchise and have control over the offer, message, pricing, look, and logos then franchising is not for you. Franchising encourages entrepreneurial spirit but only to a point. A good franchisor will not allow franchisees to do their own thing as it will ultimately dilute the value of the brand for all who have invested in it. A good franchisor will have a feedback system already in place so they can listen and learn from their franchising community. This may include a franchise advisory board, focus group, steering committees, annual conferences and a help desk. Take your time, make the calls, visit the locations, ask for the latest up to date franchise disclosure document (FDD) that every franchisor is required to provide you and don’t forget to make that trip to visit the corporate office. The FDD will provide you with all the legal information about the franchisor. Franchisors are legally required to update their FDD each year with a current list of open, closed, and transferred franchises as well as a corporate audited financial statement required by the U.S. Security and Exchange Commission (SEC). The FDD will also contain estimated opening costs and in some cases earning claims for the average franchise and the highest and lowest producing units.

Finally, if you have made the decision that a franchise is a good fit for you, have a qualified franchise attorney review the FDD as well as the franchise agreement to be certain you understand every fee you will be required to pay as well as your obligation to the franchise and the franchisor’s obligation to you. Owning a franchise can be a wonderful partnership with the right franchisor and create great relationships with your fellow franchise owners, with whom you share a common bond. In addition to making a good living, you can build value and equity in your business enabling you to someday sell it or pass it down. Just do your homework and enjoy the experience— it could reward you for a lifetime!

John Leonesio is a recognized expert in the health, wellness and franchise industry. He is the CEO of The Joint…the chiropractic place . He co-founded Scandinavian Health Spas, growing it from one club to 40 clubs. In 1990, he founded The Q, the Sports Club, growing it to 20 units before selling to 24 Hour Fitness. In 2002, Leonesio founded Massage Envy.  In just 6 years, he took it from concept to a $300 million operation with more than 800 licenses awarded.

ADHD Treatment through the SHINE Protocol Model

:dropcap_open:C:dropcap_close:hiropractic patients consistently rate their care services very highly, and yet many chiropractors must work hard to find and keep patients. I argue that just because everyone needs chiropractic care, it doesn’t mean you should market to everyone. I have studied entrepreneurs for years, and have found that the most successful ones target specific groups and prequalify their target population. Niche marketing has proven successful in countless applications, but only recently has this concept been applied to the ADHD (Attention Deficit Hyperactivity Disorder) niche in the chiropractic profession.
adhdADHD is a neurological condition that is usually transmitted genetically. It is characterized by distractibility, impulsivity, and restlessness or hyperactivity. These symptoms are present from childhood through adulthood, and with a much greater intensity than in the everyday person, so much that they interfere with daily functioning. The Centers for Disease Control indicate that over 5 million children in the United States have ADHD*. Most children carry this condition with them into their adult years. 
In my opinion, I see ADHD as neither a disorder nor a deficit of attention. I see ADHD not as a disability but as a trait. When managed properly, it can become a huge asset in one’s life. Patrick Gentempo, DC, a highly revered chiropractor and founding partner of the CLA (Chiropractic Leadership Alliance), and I immediately recognized the opportunity to blend my strength-based ADHD protocols with the CLA’s clinical and neurological expertise. With the clinical guidance of Drs. David Fletcher, Kira Bailey, Steven Genopolous, and Patrick Gentempo, SHINE For Doctors—Special Help Integrating Neurological Experience—has become the profession’s leading program in the education and training of DC’s aspiring to care for the millions of people with ADHD.
These highly gifted and often highly troubled individuals are actively looking for drug-free assistance with their symptoms. SHINE For Doctors is designed to train DCs how to address and assist in the management of ADHD in children and adults using holistic, natural techniques.
The SHINE For Doctors exclusive web-based,on-demand, educational training program is chock full of comprehensive information including: ADHD content derived from my more than thirty years of experience; attention and psychological profile assessment tools; cutting-edge information about neurological retraining; comprehensive evaluation tools including patterns of spinal neural tension, hemispherisity, and visual ocular motor capacity; and clinical integration and marketing support. This was all designed to help practitioners quickly and effectively provide ADHD support within their existing chiropractic practices.
Q: How are Chiropractors uniquely positioned to help people with ADHD?

A: DCs offer something unique to the spectrum of care for ADHD clients and their families. The chiropractic profession, founded upon a deep understanding of nervous system function and its potential effect on all facets of a person’s life, health, and behavior, has long been involved in pioneering research related to the underlying causes of ADHD. In addition, a great deal of research by some of the world’s leading chiropractic experts has been devoted to developing drug-free, holistic ADHD management strategies.

Chiropractors around the globe have reported phenomenal success when working with patients with ADHD. The effect of a chiropractic adjustment upon the nervous systems of patients with ADHD has proven to be efficacious in reducing the symptoms they experience.

Q: How can a DC benefit from the ADHD multi-million dollar health care industry?

A: The answer is by aligning with a professionally branded, holistic, drug-free, neurologically based, and powerfully effective program of ADHD management that boasts association with Dr. Hallowell’s three decades of ADHD expertise. Becoming a SHINE certified practitioner automatically adds increased credibility with prospective patients and the medical community. Many of the people with ADHD have created support groups in their communities and this association will enable the DC to leverage the authority that my reputation provides. The DC is already pre-qualified with this well-educated ADHD community. In addition, aligning with SHINE For Doctors also increases the DC’s ability to expand their service offerings and reach into their community beyond the spinal care model.

Q: What commitment will this take and how will it fit into an existing practice?

A: SHINE for Doctors is a unique program of ADHD management that incorporates the knowledge, skills, and research of some of the world’s leading experts in ADHD and chiropractic technologies. It is intended for the practitioner who is dedicated to learning this intricate product, and willing to make the commitment to ensure consistent success. DCs must consider that an investment in advancing their skill sets and knowledge bases into such a growing and “in-demand” niche market serves to distinguish their practices from the rest of their competitors, establishing them as distinct and prestigious “experts” in their field.

This program incorporates easily into the scope and framework of the existing DC practice and is complete. It is composed of in-depth, on-line, and on-demand training that delivers a superior knowledge base, system of analysis, and clinical protocols designed to facilitate success using the latest in research and technologies surrounding ADHD. Some practices choose to offer the evaluations on particular days and at predetermined times so that the ADHD clinics become an add-on to their existing client base.

SHINE For Doctors does not train the DC to diagnose ADHD; rather it provides the DC with the tools to make assessments consistent for people with ADHD and to achieve success when working with this population.

SHINE For Doctors Clinical Overview

Q: What composes the clinical content of SHINE For Doctors?

A: The clinical content of SHINE For Doctors is based within the neurological model of chiropractic and also advances the practitioner’s knowledge into what can be termed “brain-based care.” The theory of neuroplasticity forms the root of the SHINE clinical protocols. Neuroplasticity refers to the brain’s ability to reorganize itself by forming new neural connections and for the brain, nerves, and nerve pathways to adjust their activities in response to new situations or changes in their environment. This approach is very much in concert with a host of new research on ADHD labeling it a “neurobehavioral” disorder; the structure and function of the individual’s neural array is directly linked to the expression of the classic, hallmark symptoms (inattention, impulsivity, and motor hyperactivity) of ADHD. Interestingly, Autism and Asperger’s syndrome are also being placed along the same “spectrum” as ADHD. The current perception is that these syndromes are all different facets of the same underlying pattern of neurosensory dysfunction that characterizes ADHD.

:dropcap_open:There are a whole host of neurosensory processing disorders whose outward symptomatic expression mimics ADHD; consequently, these systems must be carefully evaluated.:quoteleft_close:
The neural pathways through which the body’s nervous system takes in, processes, and mounts an appropriate response to sensory stimuli can be affected by many factors during development and can be altered in response to their current environment as well. Exposure to stress, in the form of physical trauma (both macro and micro), poor nutritional habits, emotional trauma, radiation, heavy metals, drugs (prescription and nonprescription), alcohol, smoking (both first-hand and passive), and a host of other factors in combination with genetic predisposition all affect neurological development and the subsequent ability of the body to process and integrate sensory information. The symptoms that define ADHD are a direct result of the struggles of an individual’s nervous system and brain to process, coordinate, and respond appropriately to stimuli coming from the world around it. As such, ADD/ADHD is commonly misdiagnosed by professionals who perhaps do not understand or do not adequately screen for sensory processing disorders, including those related to vision, hearing, and sensory “over” or “under” responsiveness. There are a whole host of neurosensory processing disorders whose outward symptomatic expression mimics ADHD; consequently, these systems must be carefully evaluated. It is important to note that it is not the goal of a SHINE for Doctors practitioner to diagnose ADHD, but rather to evaluate and assess the individual’s strengths and weaknesses in order to understand the potential source of the behaviors being observed to the best of their abilities.

shinefordoctorsThe base of the SHINE model is neurological rebalancing through the application of the chiropractic adjustment. Proprioceptors located in the joints and muscles of the spine provide the largest source of information coming through the cerebellum into the brain. It is therefore crucial to ensure that there is no neural or dural tension or stress being held in the spinal structures. Adjusting the spine affects brain and nervous system function through enhancing the quality and quantity of information being conveyed into the cerebellum and subsequently the prefrontal cortex. Therefore, it is critical that the chiropractor ensures that the spine is free of all forms of tension and stress; a structured program of neurologically balancing adjustments focused on restoring neural integrity in the patient with ADHD accomplishes this goal.

The next layer of the SHINE model is an expansion upon the basic premise of the model’s foundation, an appropriately integrated neurological system. The SHINE doctor will use the results of their clinical analysis to create an individualized program of Neuro-Integrative Movements (NIM’s) designed to strengthen, balance and improve brain function. The NIM’s training exercises work precisely to strengthen specific neuro-sensory pathways, such as cerebellar function, balance and proprioception, vestibular function, basic visual and ocular-motor function, core strength and stability, and right vs. left hemispheric re-balancing. By isolating and strengthening specific pathways through consistent training protocols the individual’s ability to integrate and process information is improved. It is through this re-training process that the brain is able to better interpret incoming information and mount a more appropriate motor response, decreasing the outward expression of ADHD symptoms.

The apex of the Life Essentials model is Metabolic Shift. There is a characteristic association of brain and gut dysfunction in those with ADHD that needs to be addressed in order to create positive symptomatic shift. Of course, the metabolic status and digestive function of each person is unique, but there is a wealth of scientific research into the characteristic patterns of gut function, inflammation, and food sensitivities of those with ADHD. The Metabolic Shift protocols of the SHINE program focus upon two principles: eliminating inflammatory and low nutritional status foods from the diet (gluten, casein, sugars, artificial preservatives, and colorants) and supplementing with nutraceuticals that augment neurological and digestive function while suppressing systemic inflammation (EFAs, probiotics, zinc, vitamin B6, magnesium to start). When the brain is given the appropriate fuel for optimal function, and pro-inflammatory elements are removed, we once again see an upshift in function and a downshift in symptomatic behaviors.

shinefordoctors2The SHINE for Doctors clinical care model is designed to create maximal healing and reorganization within an initial 90-day window of transformative shift. It was also created to integrate as seamlessly as possible into a chiropractic practice. The SHINE patient can be adjusted during the normal flow of patient interactions, with some coaching and monitoring of the NIMs exercise protocols and dietary changes delivered at measured intervals. Rebalancing a person’s neural and metabolic function in combination with Dr. Hallowell’s unique approach to coaching and facilitating success, provides a phenomenal platform for change within the patient with ADHD. Patients and those close to patients (parents, teachers, and coworkers) report improved school and work performance, better behavior, a happier home, better teacher, student, social, work, filial and romantic relationships, a sense of “feeling” better both emotionally and physically along with better sleep and increased ability to focus and improved self-esteem.

SHINE For Doctors is the ADHD choice for the Chiropractic profession

Dr. Edward Hallowell is instantly recognizable within the medical and educator communities and his position as a co-creator endows credibility and prestige upon the DCs implementing SHINE for Doctors into their practices. It is the ideal program for practitioners who wish to offer superior service to the ADHD population, access an increased market share, generate new income streams, and distinguish themselves from the rest of the chiropractors in their region. This program is poised to be a game changer in the chiropractic profession; the goal is to change the lives of a million patients and families of those with ADHD. If you are a keen and self-motivated chiropractor who wishes to be a part of this phenomenal community, SHINE for Doctors is your best avenue to achieve unique practice success.

To learn more, visit or

Edward Hallowell, M.D. a leading authority on ADHD,  is the co-founder of the SHINE For Doctors program. He is a gifted psychiatrist, a NY Times best selling author, and was on the Harvard Medical staff for over 20 years.  He is the founder of the Hallowell Centers in New York City and Boston, and has appeared on numerous national TV programs including Dr. Oz, Oprah, Dr. Phil and Good Morning America.  You may contact Dr. Hallowell at [email protected] or visit

Kira Bailey, DC, the Clinical Implementation Director at SHINE For Doctors, is a co-contributor to the chiropractic clinical portion of the SHINE for Doctors program. She has a large family-oriented chiropractic practice, and has spent the last few years creating and operating a successful ADHD management center in Ontario, Canada. You may contact Dr. Bailey at [email protected] or visit

Chiropractors Fighting Drug Abuse

:dropcap_open:O:dropcap_close:ne of our jobs, as doctors of chiropractic, is to fight the wildly excessive use of prescription and recreational drugs.  Do you realize that The National Institute on Drug Abuse has found that one in nine youths abused drugs in the past year?  In addition, in 2011, seven percent of 8th graders, 18 percent of 10th graders, and 23 percent of 12th graders used marijuana¹.
drugabuse78After marijuana, prescription and over-the-counter medications are the most commonly abused drugs among teenagers. These include Vicodin, Adderall, tranquilizers, cough medicine, MDMA, hallucinogens, oxycontin, and sedatives.² 
There is no question that America is a drug-addicted nation. The U.S. has the highest level of illegal drug use in the world. Americans are four times more likely to report using cocaine in their lifetime than the next country with the next closest level of cocaine use. 
But that is not all. Americans also lead the world in using doctor-prescribed drugs as well! A recent study, based on the consumption of prescription drugs for 14 different diseases in 14 different countries, showed the same result. Please note that this study was not looking at prescription drug abuse, but rather studying how much medicine was prescribed by doctors for diseases like cancer, neurological diseases, hepatitis, etc.
Americans took more medically-prescribed drugs per person than the inhabitants of any other country in the world! After the U.S., Spain ranked second and France was third. This means that the U.S. ranks number one in both drug abuse and use of medically-prescribed drugs!³  We have a big job on our hands to try to change this horrible situation.
As doctors of chiropractic we must view these statistics with alarm. The fact that American adults and young people use legal and illegal drugs at such an alarming rate means that we are in the midst of a serious problem. Yet, the laws that have been passed have not changed the situation. In fact, if you look at countries like the Netherlands where it is legal to use drugs, the abuse of prescription medication and recreational drugs is significantly lower than in the United States!4   
To stem the tide of rising drug abuse we must promote natural healthcare and healthy living. Succeeding at this goal requires us to educate patients about the safety and efficacy of natural health care. Part of this natural health focus is to convince patients to use natural substances to replace prescription drugs, with their well-known and toxic side effects. Our first step is to understand the most popular prescription medications and the natural alternatives.
One of the main areas of concern for doctors of chiropractic is the abuse of prescription and over-the-counter medications for pain and inflammation. The most popular medications include ibuprofen, which is sold as Advil, Motrin, and Nuprin.5  Acetaminophen, which includes Excedrin, Aspirin and Tylenol, Aspirin, and naproxen (Aleve) are also extremely popular.6  It is common for patients to be prescribed muscle relaxants, prednisone, a corticosteroid, Celebrex, a cox-2 inhibitor,7 codeine, and Vicodin. What are the alternatives?
There are many proven remedies that can help pain and inflammation. The popular natural supplement turmeric is probably the most studied and possibly the most affective anti-inflammatory available. A component in turmeric, curcumin, which is an ingredient in Indian curry, reduces inflammation in many painful conditions such as arthritis and psoriasis. Like Celebrex and Vioxx, turmeric is a cox-2 inhibitor.  There are a number of combination supplements that contain turmeric; it is commonly combined with ginger, holy basil, boswelia, bromelain, and white willow. Common dosages are 1,000 to 5,000 mg or more per day.
Fish oil, including a number of different types of omega 3 fatty acid supplements, also has powerful anti-inflammatory affects. It breaks down into chemicals called prostaglandins, which reduce inflammation. Studies have shown that by taking fish oil, many patients are able to reduce their anti-inflammatory medication significantly or stop entirely. Common dosages are 1,000 to 5,000 mg or more per day for the reduction of inflammation.
:dropcap_open:It is common for patients to be prescribed muscle relaxants, prednisone, a corticosteroid, Celebrex, a cox-2 inhibitor,7 codeine, and Vicodin.:quoteleft_close:
For pain it is not uncommon for a patient to take 2,000 to 8,000 milligrams daily of Glucosamine Sulfate. Glucosamine Sulfate helps to restore synovial fluid and helps to regenerate cartilage. It is often combined with Chondroitin Sulfate and Methylsulfoneal Methane (MSM). This combination of three ingredients is a common remedy for inflammation and pain.    There is a significant amount of research that has documented that individually or in combination these supplements can not only reduce pain but also improve the health and quality of cartilage. 
Arnica is another popular remedy, although it is less well understood and does not have as much research behind it as turmeric and glucosamine sulfate. As a topical lotion or ointment, the arnica herb has been shown to be anti-inflammatory.
It is also used as a homeopathic remedy. However, because the mechanisms for homeopathy are so poorly understood, it is hard to find much quality research.
Doctors of chiropractic must also be aware of the fact that many of their patients could have pain from the side effects of statin drugs. Statins, the most widely prescribed medication for high cholesterol, can cause many types of joint and muscle pain. Most of us do not realize that approximately half of the men ages 65 and over and almost 40 percent of the women take statins!  That is a startling statistic. In addition, 25 percent of the reported statin adverse side effects include muscle pain! Diagnosing pain from statins is difficult because the onset can be anywhere between four weeks and four years after starting statins. 
There are alternatives to statins. Red rice yeast is probably the most popular and well-studied supplement to lower cholesterol levels. One to two grams of red rice yeast has been shown to significantly reduce cholesterol levels. In addition, four to thirteen grams of glucomannan, 3000 to 15000 milligrams of beta-glucan or 200 to 500 micrograms of chromium have all been shown to lower total cholesterol, triglyceride, and low-density lipoprotein-cholesterol. 
For those doctors who are interested in laser therapy, there is also a growing body of research that indicates that laser therapy can potentiate the effect of drugs and supplements when the laser is focused on the area that requires regeneration.
In summary, there are many common problems where over-the-counter and prescription drugs can be replaced with natural, healthier nutriceuticals. By continuing to focus on alternatives to medication, doctors of chiropractic will be helping to thwart America’s addiction to prescription and over-the-counter medications.
  1. National Institute of Drug Abuse, July 2012.
  2. WHO World Mental Health Surveys, 31 Mar 2009 
  3. Extent and causes of international variations in drug usage: a report for the Secretary of State for Health, July 27, 2010.
  4. Extent and causes of international variations in drug usage: a report for the Secretary of State for Health, July 27, 2010.
  5. The Physician and Sports Medicine 38 (1): 132–138.
  6. WebMD Health News, April 20, 2011
  7. Food Funct. 2012 Jul 26. 
  8. Br J Clin Pharmacol. 2012 Jul 6
  9. Ther Adv Musculoskelet Dis. 2012 Jun;4(3):167-80.
  10. BMC Complement Altern Med. 2011 Jun 27;11:50
  11. Int J Rheumatol. 2011;2011:969012.
  12. Holist Nurs Pract. 2008 Jul-Aug;22(4):237-9.
  13. Med Health Care Philos. 2012 Apr 27
  14. Harvard Health Publications, Statin use is up, cholesterol levels are down: Are Americans’ hearts benefiting?, April 15, 2011.
  15. J Cardiovasc Pharmacol Ther 2006; 11: 105-12. 
  16. Ann Intern Med 2002; 137: 581-5. 
  17. Evid Based Complement Alternat Med. 2012
Curtis Turchin, M.A., D.C. is an expert in the field of laser treatment, low force adjusting and therapeutic exercise. He has published 4 books and more than 20 journal articles on chiropractic and laser therapy. Dr. Turchin is the author of the best-selling book, Light and Laser Therapy: Clinical Procedures, the authoritative text on clinical laser treatment, as well as Veterinary Laser Therapy, and Treating Addictions with Laser Therapy. He has lectured at many chiropractic colleges and state associations. If you have any questions, please feel free to contact him. Contact him at: [email protected] or 650-224-8789. His teaching website is:

Evidence-Based Care vs. Subluxation Care: Are they Mutually Inclusive or Exclusive?

:dropcap_open:A:dropcap_close:s published by the University of North Carolina at Chapel Hill, “The most common definition of EBP [evidenced-based practice] is taken from Dr. David Sackett, a pioneer in evidence-based practice. EBP is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research'” (The University of North Carolina at Chapel Hill, 2010,
As the University of North Carolina at Chapel Hill goes on to explain, EBP is the integration of:
  1. Clinical expertise: The clinician’s cumulated experience, education and clinical skills.
  2. Patient values: The patient’s own personal and unique concerns, expectations and values.
  3. The best research evidence into the decision-making process for patient care: The best evidence is usually found in clinically relevant research that has been conducted using sound methodology.
spinereference“The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually triggered by patient encounters, which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders. Evidence-based practice requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature” (The University of North Carolina at Chapel Hill, 2010).
Wilbeck, Murphy, Heath, and Thomson-Smith (2011) report acute-care nurse practitioners now have metrics to evaluate procedural competencies based upon evidence-based research and care (EBR). Cuellar, Rogers, and Hisghman (2007) report healthcare providers treating sleep disorders in older adults use EBR to provide implications for care. Brady and Smith (2012) report physiotherapists working with high-risk neonatal patients used EBR to achieve a standardized level of competence and enabled the identification of the learning needs required to ensure a certain level of competence. Miller and Skinner (2012) report midwives certify home birth as a less invasive process based upon EBR. These are just a scant few examples in the healthcare industry of how evidence-based research and practice is being used as a tool to improve the quality of care of practitioners along the broad spectrum of healthcare providers.
Evidence-based practice is not unique to chiropractic, only to many in concept and practice because as a profession, our culture and history have been based upon results in our individual offices with a poor infrastructure for research and reporting due to lack of funding. This can possibly be traced to “formal medicine’s” continued attack on chiropractic and their having control over governmental research dollars. There are also large splinters in the profession moving in different directions, resulting in each faction independently seeking control.
Reggars (2011) reported a parallel in Australia: “The 1970’s and 1980’s saw a dramatic change within the chiropractic profession in Australia. With the advent of government regulation, came government funded teaching institutions, quality research and increased public acceptance and utilization of chiropractic services. However, since that time the profession appears to have taken a backward step, which in the author’s opinion, is directly linked to a shift by sections of the profession to the fundamentalist approach to chiropractic and the vertebral subluxation complex. The abandonment, by some groups, of a scientific and evidenced based approach to practice for one founded on ideological dogma is beginning to take its toll” (p. 1). Although Reggars concluded that the root of chiropractic’s “backward step” is the ideological dogma of the subluxation practitioners, he is both partially correct and concurrently omitting the other half of the equation.
The first step in moving forward and understanding the full spectrum of the issues is to take a stark look at the statistical facts versus beliefs and rhetoric. In 2010 Davis, Sirovich and Weeks reported that chiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006. This represents 4.12% of the population according to the 2003 population reported by the Encyclopedia of the Nations. Davis et al (2010) also reported that in the early 1990s, chiropractic was utilized by 7.7% of the United States adult population, realizing a net loss of utilization of 3.58% in just a decade.
While Reggars lays blame on the “subluxation dogmatists,” we cannot forget our heritage and history of what got us to caring for 7.7% of the population: Results through nothing more than the chiropractic adjustment. Treating patients with asthma, colitis, eczema, headache, migraine, scoliosis, ADHD and a host of other maladies resulted in both the chiropractors and their patients laying claim that chiropractic care resolved their health issues. I am not referencing or footnoting these claims because I have witnessed them firsthand and am reporting that these types of patients respond to chiropractic care in a repeated, systematized fashion. These types of patients, along with the multitudes of others that have realized pain relief from chiropractic care, have inspired generations to fight for chiropractic to attain our position in mainstream healthcare.
:quoteright_open:When one does a query in PubMed on “vertebral subluxation (VS),” there should be 100,000+ hits …:quoteright_close: 
In spite of the rhetoric from subluxation-based practitioners, when we look in PubMed and other scientific search engines, there is significant commentary but minimal reporting of evidence-based scientific conclusions. There is a growing body of low-value research in case reports, but the publishers have decided to hide that behind a curtain of profiteering, preventing the scientific community and the profession from accessing that information.  In spite of the greed or lack of accepted evidence-based research, there is one underlying fact: Results. It doesn’t take research to help patients get better—it only takes chiropractic care.
The other side of the argument is clear and powerful. Without the evidence, chiropractic will not evolve past 1895, and that is the second part of the core of the problem. When one does a query in PubMed on “vertebral subluxation (VS),” there should be 100,000+ hits on VS and asthma, colitis, eczema, etcetera, that show the evidence-based research in an accepted scientific format; i.e., how 800 patients in a controlled study showed evidence of a malady resolving with nothing but chiropractic care. We can say with a great degree of certainty that the pharmaceutical companies and many medical specialties will fight funding of any research that can lower their bottom line. These types of studies, without hospital populations of illnesses or teaching institutions associated with hospitals to funnel these populations of illnesses to a study, offer greater challenges for the chiropractic profession. In addition, the costs are significant, and chiropractic does not have the political leverage to garner governmental grants at that level. Therefore, without the evidence-based research and evidence-based practice, we will be stuck with ideology based upon empirical results in our offices: a practice designed for failure over time.
CONCLUSION: In spite of the loud rhetoric from the conservative far right fighting for subluxation only in the “1895 model” and the liberal far left fighting for severe expansion of scope in an evidence-based model only, those factions have to realize they are collectively responsible for the 4.12% of the population we now care for. The chiropractic message is so muddled that a confused public has already emigrated to alternative treatments.
PLAN: The only plan that is reasonable and that will move the profession to grow is for the evidence-based practitioners to stay the course and embrace the subluxation ideology until research catches up. Patients get well in spite of the research not being there. In addition, the subluxation practitioners must embrace the evidence-based providers and fight for and support financially real research, not just that designed to further the ideological causes, but the broad spectrum of research that will eventually conclude the truth of the true scope of what chiropractic has to offer. We must also support research by embracing our colleges and universities because, inherently, that is where the DCs, DC PhDs and others qualified to do research lend their careers. It is our only way up.

Author’s concluding note: The only way to remove the splinters and impediments for success is to have a single chiropractic organization in the United States with 50 chapters—no multiple national organizations and no state organizations. Combined, we are a political force with leverage. Splintered, we will continue to get more of the same: less and less every year.


  1. The University of North Carolina at Chapel Hill (2010, July). What is evidence-based practice (EBP)? Retrieved from
  2. Wilbeck, J., Murphy, M., Heath, J., & Thomson-Smith, C. (2011). Evaluation methods for the assessment of acute care nurse practitioner inserted central lines: Evidence-based strategies for practice. Journal of the Association for Vascular Access, 16(4), 226-33.
  3. Cuellar, N. G., Rogers A., E., & Hisghman, V. (2007). Geriatric Nursing, 28(1), 46-52.
  4. Brady, A., & Smith, P. (2012). A competence framework and evidenced-based practice guidance for the physiotherapist working in the neonatal intensive care and special care unit in the United Kingdom. Journal of Neonatal Nursing, 18(1), 8-12.
  5. Miller, S., & Skinner, J. (2012). Are first-time mothers who plan home birth more likely to receive evidence-based care? A comparative study of home and hospital care provided by the same midwives. Birth, 39(2), 135-44.
  6. Reggars, J. (2011). Chiropractic at the crossroads or are we just going around in circles? Chiropractic & Manual Therapies, 19(11), 1-9.
  7. Davis, M., Sirovich, B., & Weeks, W. (2010). Utilization and expenditures on chiropractic care in the United States from 1997 to 2006. Health Research and Education Trust, 45(3),748-761.

The Nightmare on Pill Street!

:dropcap_open:O:dropcap_close:n September 8, 1965, Dorothy Dandridge, the first black American to be nominated for an Academy Award for Best Actress, was found dead. The cause was an accidental overdose of Tofranil, an anti-depressant. 
nightmareonpillstreetMoving ahead to February 11, 2012, Whitney Houston, the world renowned singer and actress, was found dead with Xanax and alcohol in her system. Bottles of prescription drugs in her hotel room included Xanax, Valium and Ativan – all anti-depressants prescribed to treat anxiety.
Anti-depressants, anti-anxiety, and insomnia drugs truly have become “The Nightmare on Pill Street!” 
In nearly 50 years of prescribing anti-depressants the results are all too frequently the same – drug addiction, mental impairment, irrational and violent behavior, panic attacks, suicide, and death. An estimated 27,000 people a year die from accidental drug overdoses in the U.S.¹ , one death every 19 minutes! 
Clinical depression currently ranks second only to advanced coronary heart disease in the total number of days patients spent in the hospital or disabled at home. Pharmaceutical companies have overall yearly sales of $16 billion from anti-psychotics and $4.8 billion in sales of ADHD drugs ².  As of 2005, the most recent year for which data were available, about 27 million people, or 10 percent of Americans, were taking antidepressants.³ 
How did the United States – whose citizens are known the world over for their outgoing self-confidence – emerge as a leading consumer of anti-depressant and anti-psychotic drugs for social anxiety? How do those of us in the profession of holistic health and natural medicine reverse this trend
Manufacturing Mental Illness  
The appeal of pharmaceutical drugs is deceptively compelling. The allure that taking a pill can solve our health problems and make us feel good with little or no effort on our part is heavily promoted. In 2007, the pharmaceutical industry was estimated to be spending $4.8 BILLION dollars a year advertising prescription drugs directly to the public. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the official manual listing psychiatric and psychological disorders. Many health professionals believe the DSM has created mental illnesses out of ordinary life experiences. 
The DSM has a label and a code for most deviations from everyday behavior or passing mood swing that a person may experience4.  Do you experience excessive anxiety regarding separation from people to whom you have strong emotional attachments? That’s Separation Anxiety Disorder (SAD) or code 309.21. Recurring bad dreams? That may be Nightmare Disorder, code 307.47.  Then there’s the ultimate catchall for vague sadness or uneasiness, General Anxiety Disorder (GAD), code 300.02. 
By perceiving ordinary life experiences as certifiable mental illness, the patient becomes treatable by psychotropic drugs and billable through insurance companies.5
Anti-depressants are no more effective than Sugar Pills! 
The pharmaceutical industry claims (and advertises) that depression is caused by a shortage of serotonin — an imbalance the drug companies say can be corrected by a class of anti-depressants called Selective Serotonin Reuptake Inhibitors (SSRIs). These drugs prevent the body from metabolizing Serotonin, thereby increasing its presence in the brain.6  Prior to psychiatry’s proclamation that depression was caused by too little of the neuro-transmitter serotonin, few Americans were taking antidepressants. But by declaring that depression was caused by a serotonin imbalance, which could readily be corrected, Americans suffering from stress, insomnia and mild depression became far more receptive to taking serotonin-enhancing drugs such as Prozac, Paxil, and Zoloft.
Research, however, demonstrates that the pharmaceutical industry’s serotonin imbalance theory of depression is erroneous!
Scientists have known for quite some time that serotonin levels are not associated with depression. Research on serotonin has been clear from the very beginning that the most damaging thing that could be done to the serotonin system would be to impair one’s ability to metabolize serotonin. Yet that is exactly how SSRI antidepressants exert their effects.
A  2010 study published in the Journal of the American Medical Association (JAMA) found that anti-depressants are basically useless for the vast majority of people who take them. They were only effective on patients with very severe symptoms.7  Psychology professor Irving Kirsch, Ph.D., analyzed clinical data files from the FDA on published and unpublished trials; he found no significant differences between anti-depressant drugs and placebos. What he did find was extreme differences in side effects.8 
Is there a Link connecting Anti-depressants to Violent Behavior, Suicide, and Death?
A study out of the University of Southern California in 1996 looked at a group of mutant mice in an experiment that had gone terribly wrong. These genetically engineered mice were the most violent creatures they had ever witnessed. At birth they were lacking the MAO-A enzyme which metabolizes serotonin, thus their brains were awash in this neuro-transmitter. The researchers determined this excess serotonin was the cause for the extreme violence in these mice.9  
Paranoia, hallucinations, and violent behavior are all hallmark side effects of anti-depressant drugs! It now appears reasonable that anti-depressants may trigger the very symptoms they were touted to suppress. Much of the bizarre and unexplained violence in this country today may be the result of overmedication with anti-depressants and anti-psychotics. 
On November 4, 2011, in Winnipeg, Canadian Judge Robert Heinrichs ruled that antidepressants like Prozac can cause children to commit murder and concluded that a 15-year-old boy was under the influence of Prozac when he fatally stabbed a close friend. The judge’s opinion was a landmark legal confirmation of the scientific fact that the newer antidepressants like Prozac, including the SSRI and SNRI anti-depressants, can cause violence and even murder.
:dropcap_open:Psychotropic drugs are a contributing cause of adverse and dangerous mental instability, sometimes causing the victims to commit suicide or murder.:quoteleft_close:
As far back as 1991, the Citizens Commission on Human Rights (CCHR) organized dozens of individuals and experts to testify before the FDA that people with no prior history of violence became homicidal and suicidal under the influence of antidepressants. To comprehend the full ramifications of these acts of violence and the concurrent use of anti-depressants, more information can be found at The evidence is becoming overwhelmingly clear: Psychotropic drugs are a contributing cause of adverse and dangerous mental instability, sometimes causing the victims to commit suicide or murder. 
Going Back to the Future!
Stress has always been with us. It is simply the body’s nonspecific response to any demand made upon it. Stress was programmed into primitive man to provide him with the fight or flight response necessary for his survival. But modern man is usually in situations where neither fight nor flight are viable options so his stress point – unless it can be assuaged or channeled – elevates to anxiety-producing levels. Anxiety is merely the normal response to prolonged or chronic stress. Depression is the result of being unable to handle chronic stress while insomnia can be precipitated by stress, anxiety, or depression. They are all interrelated and can be treated holistically in an effective manner. 
Since the beginning of time, humans have experimented and utilized various herbs and foods for treating mood problems in an effort to maintain health. Achievements in doing so were remarkable because the plant kingdom supplies a wealth of building blocks for calmative, nervine, and muscle relaxant medicines. Unlike drugs, natural medicines address the underlying causes of stress, anxiety, depression, and insomnia while drugs attempt to treat the symptoms. Allopathic medicine is negligent in looking for the real causes of depression, such as thyroid problems, lack of exercise, a bad diet, a guilty conscience, medical problems, allergies, environmental factors, and a host of other possibilities. It’s easier and more profitable to write a prescription for an anti-depressant!
Natural Remedies for common psychological disorders 
Specific herbs, minerals, and vitamins have extensive therapeutic histories and have been clinically shown to assuage and ameliorate common psychological disorders and resolve their underlying causes without subjecting the patient to synthetic drugs which are foreign and toxic to the body. 
One of the most effective herbals to reduce stress – supported in the literature and by clinical research – is Rhodiola rosea which increases the body’s resistance to stress, anxiety, trauma and fatigue. Classified as an adaptogen, this herb exhibits the ability to increase resistance to a variety of chemical, biological, and physical stressors. Rhodiola also appears to regulate the body’s production of cortisol, a critical “stress hormone.10  Clinical studies have also shown Rhodiola to improve physical and mental performance, and specifically the ability to concentrate11  as well as reducing both mental and stress induced physical fatigue.12  Is this herb a viable alternative to plying our children with addictive ADHD drugs?  
Hops strobiles from extract is often utilized for its calming and antispasmodic effect on the nervous system.13  Hops are fast acting. A soothing, relaxing calm may be experienced within 20-40 minutes after ingesting the herb.14
One of the most effective natural medicines to reduce anxiety – supported in the literature and by clinical research – is Inositol, a natural tranquilizer proven to help the individual by combating anxiety.15  In a 1995 double-blind study by the Ministry of Mental Health at Ben Gurion University, the efficacy of Inositol was superior to fluvoxamine, a prescription antidepressant, in patients with anxiety disorders. Patients reported side effects of nausea and fatigue with fluvoxamine. Because it is water-soluble, Inositol does not produce toxic side effects.16 Gota Kola is another neural tonic herb which has been utilized as a treatment for nervous breakdown.17    
There are several medicinal herbs which have show to be effective in reducing chronic depression. One is Passiflora incarnata, which acts as a natural tranquilizer. Its analgesic effect has been demonstrated in laboratory and clinical tests.18 Passiflora works by increasing the availability of the neurotransmitter GABA (gamma-aminobutyric acid), which has a calming effect on the nerves. Again, Rhodiola rosea has been used for centuries in Russia and Scandinavia to treat both anxiety and depression.19 It has been demonstrated to effectively alleviate mild to moderate depression 
The most effective natural medicine to alleviate chronic insomnia has long been an over-the-counter insomnia remedy in Germany, France, Switzerland, Belgium, and Italy. Valerian root is a sedative herb which sleep support studies clearly show improves sleep quality and sleep latency but leaves no “hangover” the next morning as is often observed with pharmaceutical sleeping aids.20  This herb has demonstrated to be especially effective when sleep disorders are the result of anxiety, nervousness, exhaustion, or hysteria.21  Another cause of sleeplessness is magnesium deficiency. Magnesium supplementation is dramatically underutilized by conventional physicians. Seventy-nine percent of adults 55 and over are not ingesting the recommended dietary allowance (RDA) of magnesium. Symptoms of a magnesium deficiency include insomnia, anxiety, hyperactivity and restlessness with constant movement, panic attacks, agoraphobia, and premenstrual irritability.22  
nightmareonpillstreet2European medical practitioners have long utilized natural medicines and herbals to regulate psychosomatic disorders. In Europe, natural medicines are prescribed like other medications and enjoy widespread scientific and medical acceptance. All German medical students, for example, must learn phyto-medicine, and approximately 80 percent of German physicians regularly use natural medications in their practice. Unfortunately, in America pharmaceutical advertising has become so pervasive and successful that psychological drugs have become a first resort, regardless of their lack of effectiveness and their draconian side effects. (The United States is one of only two countries in the world that allow pharmaceutical companies to advertise directly to the consumer.)
The  public is finally becoming aware of how dangerous these anti-depressants are as more and more individuals go berserk on them! It’s beginning to exact a toll on our society. As holistic health professionals we understand that drugs are synthetic poisons and we simply cannot condone this poisoning of our citizens for profit to continue! Anti-depressant drugs are turning us into a nation of muddled, brain-addled addicts incapable of controlling our own emotions and behavior! These drugs are medically useless and physiologically dangerous. We have an obligation to speak out and educate our patients and the people we come into contact with and make them aware that superior natural alternatives to psychosomatic drugs are available. If we fail, the joke will be on us! 
  1. Pratt L, Brody DJ, Gu Q. Antidepressant Use in Persons Aged 12 and Over: United States, 2005-2008. NCHS Data Brief. No 76. October 2011.
  2. IMS Health National Prescription Audit PLUS.  
  3. Study: Number of Americans using antidepressants doubles – FierceHealthcare
  4. American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed January 22, 2010
  5. Friedman, R, M.D., New England Journal of Medicine (NEJM), May 17, 2012                                                         
  6. Kaplan, H.I. and Sadock,B.J. Synopsis of Psychiatry, Eighth Edition, Baltimore: Williams & Wilkins. 1998
  7.  Antidepressant Drug Effects and Depression Severity, Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD  JAMA. 2010;303(1):47-53
  8.  Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008;5(2):e45
  9. Dr. Ann Blake Tracy of the International Coalition of Drug Awareness, testimony on September 13, 2004 before the FDA.
  10. Gregory S. Kelly, ND, Alternative Medicine Review 6 (3): 293–302
  11. Shevtsov VA, Zholus BI, Shervarly VI, et al. (Mar 2003). “A randomized trial of two different doses of Rhodiola rosea extract versus placebo and control of capacity for mental work”. Phytomedicine 10 (2-3): 95–105. PMID 12725561 
  12. Darbinyan V, Kteyan A, Panossian A, Gabrielian E, Wikman G, Wagner H (Oct 2000). “Rhodiola rosea in stress induced fatigue—a double blind cross-over study of a standardized extract with a repeated low-dose regimen on the mental performance of healthy physicians during night duty”. Phytomedicine 7 (5): 365–71. PMID 110819
  13. Wohlfart, R, et al, Planta Medica, vo. 48, p. 224, 1982
  14. Stocker, H, Schweizer Braverei Rundschau, vol. 78, p. 80, 1967 
  15. Cooper, AJ, Psychopharmacology, vol 61, pp 97-102, 1979
  16. PubMed: Journal of Clinical Psychopharmacology; Double-blind, Controlled, Crossover Trial of Inositol Versus Fluvoxamine in the Treatment of Panic Disorder 
  17. Mowrey, DB, The Scientific Validation of Herbal Medicine, p 193, 1986
  18. Ambuhl, H, “Anatomische und chemische untersuchungen an Passiflor incarnata,” Dissertation Number 3830 ETH, Zurich, 1966
  19. Darbinyan, V.; Aslanyan, G.; Amroyan, E.; Gabrielyan, E.; Malmstroumlm, C.; Panossian, A. Clinical trial of Rhodiola rosea L. extract SHR-5 in the treatment of mild to moderate depression Nordic Journal of Psychiatry, Volume 61, Issue 5 2007 , pages 343–348.
  20.  Leathwood, et al, Pharmacol. Biochem & Behav, vol 17, pp. 65-71, 1982
  21. Straube, C, Therapie der Gegenwort, vol 107, pp. 555-562, 1968
  22. Baker, S.M. Magnesium Deficiency in Primary Care and Preventive Medicine, Magnesium and Trace Elements, 1991-1992; 10:251-262
Galen O. Ballard is President of Titan Laboratories and directly responsible for the products division. His background includes undergraduate studies in research at the University of Denver with graduate work at the Universities of Wisconsin and Maryland. Galen may be reached toll free at 1-800-929-0945 or by email at [email protected]

Software Clearinghouse Support Key to Improved Revenue Cycle Management

:dropcap_open:E:dropcap_close:ffective billing and claims submission processes and procedures, both during today’s current challenging economy and in better times, have been key to our chiropractic practice’s continuing health and ability to grow. Improved revenue cycle management has positively and directly impacted the level and overall quality of the patient care we deliver, as better accounts receivable yields dollars for reinvestment in state-of-the-art technologies.
lockedfilesThe same can be said for our chiropractic practice brethren. In addition to offering a wider range of patient payment options beyond cash and checks, including credit and debit cards and e-payment, increasingly sophisticated and fully useful software solutions are automating once paper-based clinical and business applications while facilitating integration with collection agencies and clearinghouses. 
These solutions serve as inexpensive tools that chiropractic practices leverage to more thoroughly capture revenue from existing patients, while also making it easier to accommodate increasing patient volumes. 
We formed the All Care Health and Rehabilitation Center here in Jefferson, IN more than 20 years ago, eons when one considers the now archaic paper-based billing and claims processes then commonly in place. Our practice only a scant two years ago began using billing and notes software and clearinghouse services. We’re still modest in size; our staff consisting of Dr. Gabe Spruch and one other physician, and Sherrie Spruch and three other support staff members. We transitioned to our current system after years of enduring painful and time consuming paper-based processes, followed by a period during which an outside billing service handled our billings and claims electronically. 
Frankly, the thought of moving billing and claims processing back under our roof was not something we initially were wildly enthusiastic about.
But we’re glad we did, and are certain that other chiropractic practices either feel the same or are seriously considering going the same route. The revenue cycle management solution has fully automated our entire suite of clinical and business processes, from scheduling and documentation, to accounting, administration and enterprise management. Our overall practice efficiencies and end-to-end payment management have been markedly improved, as has workflow as it relates to reduced billing and clerical errors, reduced accounts receivable and faster payment posting and book balancing resulting from an auto-remittance feature.
Software, by itself, unless used properly and to its full capability, won’t enable chiropractic practices to be as efficient as possible. Built-in analytics tools enable practice administrators to closely examine patient responsibilities like co-payments, deductibles, coinsurance payments and other similar fees. Reviewing these, over time, has enabled us to better identify problem areas and work with patients in addressing the most serious situations for improved revenue flow. 
:dropcap_open:We electronically sub-mit nearly all—99 percent—of our claims.:quoteleft_close: 
It’s also critical that solution providers walk physicians and support staff step-by-step, process-by-process to do so. Practices must be aware of each individual insurer’s unique policies and procedures, and learn exactly how to file claims to each. Practices therefore should choose software not only based on its functionality and cost, but also as it relates to a vendor’s ability and willingness to provide strong support before the sale as well as during and after implementation.
The best systems don’t only facilitate claims submission; their developers will also hold claims for chiropractic practices for required edits, dramatically reducing insurer rejections, speeding up payments and maximizing revenue flow. Some vendors will also electronically accept remits on a practice’s behalf, so that all the chiropractic office needs to do is download them into the billing software. Here at All Care Health and Rehabilitation, all we need to do is download a remit and the software automatically pulls up the patient’s claim and posts it to the account on the date of service.
What a time saver! Other revenue cycle management features built into some software solutions provide practices with all pertinent information relating to individual claims and provide the ability to resubmit claims directly through the vendor’s website for a seven- to 10-day turnaround, depending on the insurer. We electronically submit nearly all—99 percent—of our claims. Because not every insurance company accepts electronic claims, it’s also helpful to choose a software vendor that will ease your practice’s burden by filing paper claims for your practice.
As we stated, today’s economic conditions are less than stellar, with high unemployment and frequent changes in employer healthcare coverage. Patients like never before are struggling to meet direct medical costs. Chiropractic practices that offer flexible, consumer-friendly payment options provide patients with increased incentives to make prompt payments, while software solutions from supportive vendors accelerate the revenue cycle through improved billing and claims processes.
Combined, these policies, procedures and solutions generate improved revenues and profitability. The increased cash flow enhances a chiropractor’s ability to provide higher quality care with added resources for medical technology investments, and lower patient, physician and staff member stress levels.
Dr. Gabe Spruch, with his wife Sherrie Spruch, is the co-founder of All Care Health and Rehabilitation Center, launched in 1990 as All Care Chiropractic. Dr. Spruch is both a chiropractic physician and licensed professional acupuncturist. He and his staff work to help patients achieve better health with proper nutrition, exercise, structural alignment and balanced internal energy. You can visit the website at: or call  (812) 288-7000. His practice uses ZirMed for their revenue cycle management solution. For additional information, visit the website at:
Sherrie Spruch, co-founder of All Care Health and Rehabilitation Center with her husband, Dr. Gabe Spruch, serves as the center’s practice manager. In addition to overseeing day-to-day office operations, Sherrie shares with patients her wealth of knowledge about the importance of natural health care. You can visit the website at: or call (812) 288-7000.

From Checks to Mobile: Three Simple Methods for an Integrated Payment Processing Strategy for Chiropractors

:dropcap_open:C:dropcap_close:hiropractors, like many other healthcare providers, tend to operate individually or in small groups (1-3 providers) with a limited amount of administrative staff to manage cash flow and collect for services rendered. Matt Llewellyn, VP of Healthcare Sales at BillingTree, takes a look at three methods of patient payment processing which chiropractors may use to improve collections and cash flow.
mobilebankingThere are distinct challenges in terms of managing cash flow and collecting patient payments for smaller professional practices with limited back-office staff to manage all the administrative processes needed to support the business. 
These three optional patient payment processing methods can help practices implement simple procedures to improve operational efficiencies through the use of readily available technologies. The payment options range from the basics of processing paper check payments more efficiently to the more advanced payment options such as SMS and personalized web portals.
Method One: ACH – every check counts!
Although many people elect to pay bills with debit and credit cards, a significant number of payments are still made by check. If your practice accepts paper checks there is no reason for you to continue the paper process to deposit the funds. Why not convert the check to an electronic deposit? 
One easy way to convert the paper payment to an electronic deposit is through the use of a scanner that will convert the check to an Automated Clearing House (ACH) transaction. The check is converted to an electronic file which is then sent through ACH payment-processing gateways. ACH payments processing provides more efficient cash management capabilities and lower costs than traditional paper payments processing. Providers that use ACH processing benefit from an accelerated availability of funds, with cleared funds deposited directly into their accounts.
One thing you want to be sure of when converting paper checks to an ACH transaction is that the checks being converted are coded with the correct SEC code. The code used varies based on how the check was received as well as whether the check is from an individual or a business.  
Another factor to consider is having the ability to automate check representment when checks do not clear the first time. You will find there are automated processes which will enable you to pre-set times of the month for check representment, choosing times when the patient is more likely to have funds in their account to cover the check.
Method Two: Mobile payments are on the rise
:dropcap_open:By providing the patient with this new payment option your office is expanding the patient preference communication offering.:quoteleft_close: 
You cannot walk down the street or be in a public place today and not see individuals using smart phones. There is a growing desire for people to interact with others through their smart phone, and patient-to-provider interaction is no exception.
Do you provide your patients with a “preferred method of communication” option as part of your registration process (i.e. mail, e-mail, cell phone, etc.)? If you do, it’s likely that some will select their cell phone as the option. For those that choose to leverage their cell technology, why not offer them the chance to actually pay their bill with their mobile device?
Today, patients can pay their bills through their smart phone, and this manner of payment forms a convenient way for patients who are on the go or who are prone to be more responsive when they are messaged on their mobile device. Technology today enables a patient to establish an e-wallet, secured with the use of a user-defined PIN and command on their phone. Your billing staff can leverage available technology to reduce costs associated with consumer contact, including time sensitive notices and recurring check reminders, as well as the expense of traditional paper billing. 
As an added benefit, your office is adapting to the changing environment in which the patient experience is becoming a measured metric in the care cycle.  By providing the patient with this new payment option your office is expanding its patient preference communication offering. 
Method Three : Electronic Payment Portals – providing patient access to information online 
The Government is working hard to increase the adoption of an Electronic Health Record (EHR) and patient portals. If your office is already offering a portal to your patients, adding web payments functionality is a logical next step. If you already accept web payments then that’s great news!  
A few things to consider when offering web payment options to your patient are: 
  1. User Friendliness – to make the process as easy as possible for the patient to pay 
  2. Type of payment options – can you only make a single payment or can the web solution accept recurring payments?
  3. Using Personal URLs (PURLs) for patient payment – encourage electronic payments from paper statements and invoices, so customers can quickly pay online.
In summary, there is certainly a shift occurring in patient payment responsibility, wherein the patient will have more out-of-pocket funding for care. In addition, technology is evolving and the way patients prefer to interact is changing in line with this.  
The question to be asked and answered is: “Is my practice leveraging available technology which best meets the expectations of my patients, while also improving operational efficiencies and cash flow?”  
If the answer is “no” or “I’m not sure,” then consider implementing one or more of the above methods to integrate solutions that will help you answer this question with a resounding “YES”.
Matt Llewellyn joined BillingTree in 2012 bringing over 20 years of experience in healthcare and IT. As Vice President of healthcare sales and new business development, Matt is responsible building on the existing success within the vertical and to identify and implement new partner integrations from within the healthcare market. Prior to joining BillingTree Matt held senior leadership roles at multiple organizations including TVP, Channel Strategies for RelayHealth and VP  of Hospital Sales, Western Region, for NDCHealth. You can call at  (602) 443-5914 or email: [email protected].

Subluxation vs. Disc Herniation

:dropcap_open:C:dropcap_close:hiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006 as reported by Davis, Brenda and Williams in 2010. This represents 4.12% of the population, considering the 2003 population reported by the Encyclopedia of the Nations. Davis et al. also reported that in the early 1990s chiropractic utilization was 7.7% of the United States’ adults, realizing a net loss of utilization of 3.58% in just a decade. The reasons are many and in spite of the growing interest in the utilization of complementary and alternative medicine (CAM) nationwide, with chiropractic as the largest CAM provider, the numbers are still dwindling. The chiropractic profession must take an honest look at the numbers and realize that it can no longer be “business as usual” or risk that the utilization will continue dwindling until we no longer make the positive impact on society that we currently do. 
subluxationvsdischerniationFiore in 2012 reported that accurate diagnosing was critical to the success of the chiropractic profession in order to be credible in the health care community. He also reported that many chiropractors hide behind the definition of chiropractic as the “…art, science and philosophy of locating and correcting nerve interference…” and continued on to say “This allows the chiropractic profession to have great latitude…but does not excuse us from making an incorrect diagnosis.” In order for us to understand a spinal related problem or any pain, we must not create a correct hypothesis, we must conclude an accurate diagnosis before we construct a prognosis and treatment plan. According to Frank Zolli, DC, the Dean of the University of Bridgeport College of Chiropractic for over 20 years, “every chiropractic student during their doctoral training learns at the most basic level of training that you must have an accurate diagnosis and then create a prognosis before you treat your patient.” Dr. Zolli continued by saying that this is taught in every CCE accredited chiropractic college.
With the advent of new and not so new technology, we no longer have to hypothesize or theorize. It’s called the MRI and every licensed doctor of chiropractic in the United States has within their scope the ability to refer a patient for an MRI (with the exception of Medicare, as the Federal Government, through their actions and regulations, has much less regard for the well-being of our seniors). Chiropractors have to realize that technology takes away much of the hypothesizing and allows us to conclude with a great degree of certainty an accurate diagnosis: the foundation of the treatment plan. 
When we look at disc issues, this gives the chiropractic profession a universal platform to becoming and being considered by medicine to be the “Spinal Primary Care Providers”. Back pain, inclusive of disc pathology, is a thorn in the sides of most primary care providers (PCPs) and a diagnosis they universally refer to orthopedic surgeons for lack of a better alternative.Orthopedic surgeons are centered on surgery, with their $225,000+ malpractice costs, and summarily dismiss most non-surgical cases to physical therapists, who in turn render much poorer outcomes, according to Cifuentes et al. in 2011, for back related issues compared to chiropractic care.
Cifuentes  concluded that chiropractic care during the  disability episode resulted in:
  • 24%   Decrease in disability duration of first episode compared to physical therapy 
  • 250% Decrease in disability duration of first episode compared to medical  physician’s care 
  • 5.9%  Decrease in opioid (narcotic) use during maintenance care compared to physical therapy care 
  • 30.3% Decrease in opioid (narcotic) use during maintenance care compared medical  physician’s care
  • 19%   Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
  • 43%   Decrease in average weekly cost of medical expenses during disability episode compared to medical  physician’s care
According to the U.S. Department of Health and Human Services in 2008, there were 490.41 million visits to primary care medical doctors (PCPs) in the United States that year, when almost every United States citizen visited a primary care doctor across multiple health care platforms. The penetration of PCPs nationally is somewhere between 95-100% of the population, where chiropractic is 4.12% of the population. Understanding the penetration and influence PCPs have over the population and the positive “evidence based chiropractic results” that medicine has long asked for, the chiropractic profession is now poised to become the “Spinal Primary Care Providers”, with one proviso. 

We need to take our place as spine specialists and not just subluxation specialists to conclude accurate diagnoses and converse in a language that is universal and inclusive to both chiropractic and medicine. In order to do that, we need to learn disc and spinal pathology as a beginning.
When utilizing MRI, there has to be a criteria or protocol for ordering a scan and then an understanding of the findings. This author has long held that in the presence of a significant radiculopathic or any myelopathic finding an immediate MRI is warranted BEFORE you create a prognosis and treatment plan. In short: don’t touch the patient until you know what the diagnosis is. This protocol has been well documented in the literature as evidenced by the Fish, Koboyashi, Chang and Pham, who also concluded that symptomatic radiculopathic findings or central canal stenosis (as found in myelopathies) require MRI for conclusive diagnosis prior to treatment.
When interpreting MRIs it is imperative that each doctor be proficient in interpreting their own film. Lurie et al. reported in 2009 that “…the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases,” meaning that general radiologists inaccurately report what is wrong with your patient almost half the time and you are often delivering a “high velocity thrust”, known as an adjustment/manipulation, with wrong information. It is here that you start to become the spine specialist and can guide the PCP in their referral pattern based upon your clinical excellence. The “best of the best” read their own MRI images, no differently than the spine surgeons who will not operate unless they have firsthand knowledge that they know is accurate. Chiropractors are no different.
When interpreting MRI images it is important to understand accurate nomenclature. The following was reported by Bailey in 2005:
Disc Bulge: Synonymous to disc degeneration. 

Author’s note: a circumferential degeneration over time evidenced by a thinning of the disc with the nucleus pulposis still within the confines of the annulus. The disc bulge or expansion must cover greater than 50% of the disc circumference and is usually close to 100% of the circumference.
Annular Tear: Tear or fissure in the annular fibers, either radially or concentrically. 

Author’s note: The outer 1/3 of the annular fibers are innervated by the A, B and C fibers commonly known as the recurrent meningeal nerve and as reported by Lee et al. can cause pain in either annular tears or irritated degenerative discs.

Herniation: Displacement of the disc beyond the limits of the disc space.

Author’s note: Tear in the annulus where the nucleus pulposis material goes outside the confines of the nucleus.
Focal Herniation: Less than 25% of the disc circumference.

Author’s note: Where the herniation covers 25-50% of the disc circumference.
Broad Based Herniation: Between 25-50% of the circumference of the disc circumference
Author’s note: Where the herniation covers 25-50% of the disc circumference.
Protrusion Type Herniation: Author’s note: Where the base is greater than the apex in any plane.

Extrusion Type Herniation: Author’s note: Where the apex is greater than the base in any plane.
According to Robert Peyster, MD, DABR-NR Neuroradiologist, Chief of Neuroradiology, State University of New York at Stony Brook, herniations are traumatically induced.
McMorland et al. (2010) found that 60% of surgical candidates had successful outcomes with chiropractic as an alternative to many disc surgeries. The evidence shows chiropractic was highly effective for patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. What about the other 40%?
Over the last 23 years, Magdy Shady, MD, Neurosurgeon, Neuro Trauma Fellow, has worked with this author to develop a clinical protocol to determine when chiropractic was indicated in a disc herniation patient. If there is room anywhere around the cord or root, then adjusting/manipulation is a clinically indicated first line treatment. In the absence of any room around the cord or disc, then chiropractic, based upon the increase in intrathecal pressure created in the adjustment/manipulation, puts active chiropractic care in the second position after the disc has been reduced. 
Over the decades, that protocol has been followed strictly to the benefit of thousands of patients, where surgery was needed only in a small population of those patients and the first line treatment was bed rest, cryotherapy or anti-inflammatory medication managed by the neurosurgeon until chiropractic was indicated via a combination of a follow up clinical evaluation and MRI.

Knowing the difference between aggressive chiropractic treatment or waiting a few days or weeks until the swelling has reduced is a result of making an accurate diagnosis, prognosis and treatment plan. That is also the foundation for relationships with PCPs and being part of a health care team involving multiple disciplines where the chiropractor is the “Spinal Primary Care Provider” and coordinator of health care. 
The PCPs appreciate the relationship because it relieves them of the spinal-related patients constantly ending up in their offices as though through a “revolving door” because orthopedics and physical therapy are not the solution and often only serve to delay the exacerbations that end up in the PCP’s office over and over.
Becoming expert in disc pathology and reading MRIs is the first step towards becoming a spine specialist and tapping into the 95-100% of the population cared for by PCPs. Having control over an accurate diagnosis and orchestrating the triaging of the patient puts chiropractic in the epicenter of spinal-related care and relieves the PCPs of what they consider a “burden to their practice.” 
It can no longer be business as usual and becoming proficient in disc, MRI and spine care does not change how you care for your patient, nor the philosophy with which you practice. There is room in both the subluxation and structural models of practice. This level of clinical excellence simply makes you a better doctor and opens doors to allow you to become part of the health care team in your community and will ultimately increase awareness and utilization of cost-effective chiropractic management of non-surgical spinal conditions. 

  1. Davis, M., Sirovich, B., Weeks, W. (2010).Utilization and Expenditures on Chiropractic Care in the United States from 1997 to 2006. Health Research and Education Trust, 45(3), 748-761.
  2. United States Population (2012), Encyclopedia of the Nations, Retrieved from:
  3. Fiore, J. (2012). Subluxation vs. Herniation: A New Paradigm for Chiropractic. The American Chiropractor, 34(8), 14-18.
  4. Primary Care Workforce Facts and Stats No. 1, The Number of Practicing Primary Care Physicians in the United States, (2008) U.S. Department of Health and Human Services, Retrieved from:
  5. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  6. 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.
  7. Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations. Spine, 34(7), 701-705.
  8. Lee, J. M., Song, J. Y., Baek, M., Jung, H. Y., Kang, H., Han, I. B., Kwon, Y. D., & Shin, D. E. (2011). Interleukin-1β induces angiogenesis and innervation in human intervertebral disc degeneration. Journal of Orthopedic Research, 29(2), 265-269.
  9. Bailey, W. (2005). A practical guide to the application of AJNR guidelines for nomenclature and classification of lumbar disc pathology in Magnetic Resonance Imaging (MRI). Radiology, 12(2), 175-182.
  10. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.

Is Transitioning to a Cash-Based Practice Right for You?

:dropcap_open:B:dropcap_close:etween our two companies, Cash Practice and ChiroHealthUSA, we hear from hundreds of doctors a month who think they want to transition to an all cash practice. The reasons are varied, but are most commonly related to frustrations in dealing with insurance companies, hearing about or being involved in a recent audit, dwindling reimbursements and increased demand for pre-cert paperwork or documentation.
therulebookWe also find there are many misperceptions about going all cash. Such as, going ALL cash means you are finally free to do what you want in making recommendations to all patients about their care. You can opt-out of every network and disregard terms of the PPO agreements. And, the BIG LIE many have heard is if you are all cash, you are immune to all the rules and regulations from your Board of Examiners, all the way up to CMS and the OIG, when it comes to proper  documentation, billing, coding, discounting, state and federal inducement violations and other red tape including HIPAA.    
As is usually the case, the truth lies somewhere in the middle. Going all cash or transitioning to a more cash-based practice can be liberating in many ways, but it is not a panacea. If your State Board of Examiners has outlined the minimum standards for documentation, you are still bound by those standards, regardless of who is paying the bill.
If you see patients who may be insured, they will expect to be provided with a proper receipt reflecting your diagnosis with the proper ICD-9 codes, the procedures you performed with proper CPT codes and, if the patient submits the receipt to their insurance carrier for consideration, you may certainly expect to receive a request of records to support medical necessity.  And, while you may have been “PAID” by the patient and think you are in the clear 100%, if your record keeping and coding is not up to par, you can probably expect a complaint filed with your board from a patient who may have SWORN they did not intend to send in receipts to the insurance carrier since you are all cash.
Now, as soon as we write this, we are going to hear from someone who says, “My attorney says if I have them sign this form that they won’t file, or that they can’t file a claim when they pay cash, I’m in the clear.”  If that is the case, good for you and make sure you have that attorney on retainer because there is NOTHING worse than dealing with a “ticked-off” patient who decides later that they want their insurance company to pay them back and YOUR notes or records are sub-standard. So much for being immune from rules and regulations by going all cash! 
Another area where doctors often think going all cash brings them freedom is in making treatment recommendations and offering varied forms of payment plans or pre-paid plans, especially if the patient is paying cash. Once again, while there is some freedom from not being involved in insurance networks, there are other rules and regulations that may come into play. 
:dropcap_open:In several states, Boards of Examiners have promulgated rules about pre-pay plans and require escrow accounts to be utilized.:quoteleft_close: 
In several states, Boards of Examiners have promulgated rules about pre-pay plans and require escrow accounts to be utilized.  Why? You can bet it is because of patient complaints related to refunds!  Also, there are some states that consider collecting in advance for health care services to be the “business of insurance” and you must have an insurance license issued by the state.  
Finally on this topic, keep in mind that if you are seeing a patient with insurance, even if YOU are out of network, the patient has certain obligations as a policyholder, such as paying the required deductibles and copayments. Be aware that if you, even as an out of network provider, offer pre-payment plans that include any discounts on the patient’s cost-sharing portions, the insurance company may not be liable for any payment or reimbursement back to the patient.  
Diversified Isn’t Just a Chiropractic Technique
We are seeing that more and more doctors want to become less dependent on insurance. And there are some who want to go 100% cash, but they are not the norm. For most doctors, the smart move is to do what your investment banker might suggest, “Diversify”. Meaning, don’t be 100% anything! Have a good mix of insurance, personal injury, workers’ compensation and build up your cash side of the practice. This will bring you the ultimate in practice stability and peace of mind by not having your practice disappear overnight if all your financial eggs are in one basket. For doctors who were ALL PI or workers’ comp and practiced in states where changes to these payment methods were implemented, ask them what it is like the day AFTER the law changes and PI or workers’ comp vanished.
As long as you understand that the transition to a cash-based practice does not make you invisible from regulators or grant you immunity, then we encourage you to consider diversifying your practice to include more cash-based patients and become less dependent on insurance.
Transitioning to Cash-Based Practice has MAJOR Benefits Even When the Patient Has NO Insurance Benefits! 
There are three major benefits of placing your patients, particularly cash patients, on long-term care plans. The first benefit is you rarely have patients drop out of care because “the pain went away” or “the insurance ran out”. Those are the two most common excuses doctors will state as the reason patients drop out of care. And both are completely neutralized when placing a patient on long-term care plans. So you end up with better treatment compliance.
:quoteright_open:There are three major benefits of placing your patients, particularly cash patients, on long-term care plans.:quoteright_close: 
The second benefit is a result of the prior benefit. You get better clinical results, get more referrals and become more profitable as a practice. It is pretty obvious that if your patients are staying on your care plans, they will get better and will be more likely to refer friends and family.  
We also need to state that if you are recommending long-term care plans, you better be able to deliver on the promises you make. We are not talking about just providing “pain relief” type care for a longer period of time.  
Let’s be real. If you want to deliver on the promise of wellness, you better be able to demonstrate improvements in the patient’s well-being. There are some great tools and resources available for doing just that.
When recommending long-term care plans, obviously there will be a fee for your services. It is crucial that the way you collect the fees for your care plan is setup correctly. We should start by stating what NOT to do. The idea of offering a plan of care where the end goal for all patients is to prepay for the program (i.e. prepay for a year of care) is not recommended.  Why? The challenge is, prepaying for anything (outside of chiropractic) is not the norm for people and, as noted before, could be considered the business of insurance in some states.
People are used to “financing” everything these days.  Look at how TV commercials promote a car.  Do they advertise the price of the car?  No, they tell you the lowest monthly lease payment available.  They do that because they know that the majority of people make a purchase decision with the “monthly payment” in mind rather than the total price.
So, offering your patients a long-term care plan that offers payment options is what we recommend.  By offering options, the patient will pick what works best for them. The options are monthly payments, a larger down payment with smaller monthly payments and a prepayment for the folks that want to choose that option where it is legal. We find that most people choose one of the first two options.
The last thing about collecting the fees for these plans is to consider using an auto-debit program to collect these payments.  Our experience has shown that the more often people think about the money you are charging, the more likely they will stop care. We have a policy in place to remove every situation we can that reminds them of the money.  So, no statements are mailed.  No third-party financing (i.e. Care Credit or similar plans). We securely keep their credit card or bank account information on file in a PCI compliant program and run the payments on the agreed upon date. This is no different than having a routine to submit claims every Tuesday or on the 1st and 15th. With a proper auto-debit system, it can be BETTER than insurance since there is NO waiting for reimbursement or claims rejections!
The bottom line on transitioning to a more cash-based practice is to do it for the right reasons. We encourage all of our clients, even those who choose to go 100% cash, to remember that regardless of the payer type, you should document correctly, code correctly, bill correctly and, if you discount or offer payment plans, make sure you are handling those correctly and start practicing with more peace of mind.   
Dr. Bodzin is the Founder and CEO of Cash Practice Inc, a web-based company that provides The 4-Step Process for Reducing Your Dependence on Insurance and New Patients.The Wellness Score, Cash Plan Calculator, Auto-Debit, and Drip-Education Email Systems give the practicing chiopractor tools for implementing the four steps. Dr. Bodzin speaks internationally on running a cash-based practice for Associations, Parker Seminars, Philosophy Groups and for many of the coaching companies. Dr. Bodzin can be reached at 1-877-343-8950, [email protected] or by visiting

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 has served as  president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a  Fellow of the International College of Chiropractic. He founded ConservaCareCorp, the first chiropractic network selected by the State of Mississippi to serve over 195K covered lives in the State Health Plan. You can contact Dr. Foxworth at 1-888-719-9990, [email protected] or visit the ChiroHealthUSA website at

A Dash of Persistence with a Touch of Honey: A Winning Combination

:dropcap_open:M:dropcap_close:ore often than not, doctors decide about insurance participation based on the horror stories they hear from their friends. It’s not unusual for both new and seasoned practitioners to throw up their hands at the prospect of dealing with insurance companies on behalf of their patients. More doctors are also concocting ways to skirt working with Medicare. None of this is necessary. Insurance coverage is a treasured commodity that patients feel compelled to use because of the premiums they pay. A typical practice working within the boundaries of compliance and proper documentation and billing should have no problem working with third-party payers. To cultivate a healthy doctor-carrier relationship, focus on these five areas:yeswecan
  • Ensure You are Properly Credentialed
  • Understand the Expectations and Limitations
  • Know the Medical Review Policy
  • Bill and Code Correctly
  • Firmly Follow Up
Ensure You are Properly Credentialed
Every carrier has rules about who does what to whom and who gets the $5, as they say. There are two kinds of relationships possible with a typical carrier: a participating or a non-participating agreement. This is delineated by the rules associated with the contract signed. Medicare, however, is a different animal: Whether participating or non-participating, you must be registered with Medicare to see any Medicare patients. That means you have applied for provider status and are legally allowed to see Medicare patients. Chiropractors have an extra layer of regulation, in that if a chiropractic manipulative treatment (CMT) code is provided, you must be able to bill it, and without being registered with Medicare, participating or not, you can’t bill without a Medicare number. And yes, we are all aware of the nightmare getting registered with a carrier, and Medicare in particular, can be. Here is a story related by KMC University Medicare Reimbursement Specialist Naomi Chance, CPC about a recent experience she was involved in:
“It was in the summer of 2011 when a young doctor contacted me about the numerous and complicated problems he was having getting his Medicare Enrollment Applications approved. He had completed every single form required, submitted all sorts of documentation, crossed every “T,” and dotted every “I.” Still, the “Medicare Development Letters” kept coming. He documented tens of calls to his MAC carrier to inquire about all the delays. He asked all the right questions, and pleaded for their guidance and direction. Then he would wait and wait and wait. Every single time, no matter what he did, no matter how many times he reapplied, or how many times he called, wrote, faxed and yelled, his Medicare applications continued to be “DENIED … pending development.”
“Development of what?,” he cried.  He did what they asked, but it was never enough. He made corrections to the applications as they instructed him to, yet it was still never right. He was repeatedly given conflicting information by every “expert” he spoke with. One Medicare Analyst would tell him to do something one way, and yet another Analyst would tell him to do it another way. When it seemed like he should just give-up and give-in to Medicare, a friend referred him to us for assistance.
Time was running out fast because Medicare’s timely filing limit is one year. Any claims submitted for dates of service after that one year mark would deny and it was going to cost this young doctor thousands upon thousands of dollars. He felt certain he was never going to be reimbursed for all of that patient care and work! The long story made short is, that once we evaluated everything, it was clear that “action steps” would be necessary to get this young doctor’s Medicare Enrollment Applications approved, and the $125,000 in pending claims processed and paid.
We went to work fast, gathering all of the facts, data and key information, and knew exactly what had to be done. It took a lot of work, but the end result was HUGE for this doctor. Compliance was in and every one of his $125,000 worth of claims was paid.”
The moral of this story was that it nearly took a mountain to be moved to make the carrier responsible for their role in holding up the enrollment of this doctor. But the mountain WAS moved, and the outcome was favorable.  Don’t give up!

Understand the Expectations and Limitations
Every carrier will not have a fee schedule that pays what you believe your value to be, or the value of the care you’re delivering. Insurance participation is a very personal decision, made for a variety of reasons. Agreeing to accept a sub-standard fee schedule may work for you because it serves as a marketing arm for your business. Complete understanding of the difference between what the carrier feels is medically necessary, and therefore payable, and what you think they should pay for, helps manage your expectations. Being available as a participant on a plan may open the door to patients who would not otherwise come see you. This open door allows you to explain chiropractic care, the differences between “medically necessary” and “clinically appropriate” care, and who pays for which, AND allows them to know you and make a decision about you becoming their doctor. Having access to this open door may also come with limitations: lower fee schedules, contractual rules and obligations you don’t like, and other penny ante complications of working with third-party payers. That’s why it’s a personal decision. Do the following to mitigate problems later:
  • Read the contract before you sign it! Know if you are agreeing to things against your principles or methodology of treatment. Know if these agreements will affect the processes in your practice.
  • Acknowledge that insurance was not meant to pay for everything. Give the patient the simple fact at the beginning of care:  “Great news Mrs. Jones! Your carrier will contribute toward your financial responsibility in the office! Isn’t that great!” And know this: No matter how much that contribution is, it’s great. If you own it, your patient will too. 
  • Have systems and payment plans in place to help make care affordable for your patients when it is their turn to pay. Utilize a Discount Medical Plan Organization (DMPO) like ChiroHealthUSA to offer legal, network-based discounts. Help your patient understand the insurance card is not a Visa or MasterCard! 
Know the Medical Review Policy
 :dropcap_open:It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill.:quoteleft_close:
Whether you choose to work with insurance carriers as a participating doctor or not, nearly every service covered by the carrier is likely to have a medical review policy. This policy outlines the expectation of coverage, the types and descriptions of covered diagnoses, and will summarize what the carrier assumes you are doing if you are billing that service or code. For example, a contract with BCBS of Texas states that massage is a covered service. However, if the patient is receiving 97124, Massage Therapy or 97140, Manual Therapy, the doctor may not delegate that to a CA or other provider working under the DC. It is expected that the DC provides the hands-on service.  Even though the scope of practice in the state of Texas allows for delegation, the contract signed by the provider supersedes that. What if you are not a participating provider? The rules still apply! They state that the DC must always provide the service to be paid for that muscle work. Be sure you know your medical review policy for any carrier you do business with. These simple steps will help you stay ahead of the game: 
  • Create a spreadsheet and include a list of every carrier you do business with. Identify whether you are participating or not. 
  • Pinpoint each major code or code set that you use. Some carriers categorize all physical therapy procedures together, for example, while others list them by individual code.
  • Find the medical review policy on each carrier’s website for each code or code set that you use. Note any special rules or particular issues that may apply to the service as you rendered it, such as by delegation. Remedy any outpoints that are identified, and write internal policy to keep from crossing the line. 
Bill and Code Correctly
When scouring the Medical Review policy for the most typical services you render, pay close attention to billing and coding guidelines that are particular to that carrier. Although it doesn’t make sense, some carriers follow their own set of rules that are contrary to national coding principles.  Some carriers still inexplicably require the “51” modifier on the Extraspinal Manipulation code, 98943. This coding policy is outdated and incorrect, and efforts are underway to get such things updated. Meanwhile, however, whether you agree with the policy or not, if you don’t use a “51’ modifier when billing 98943, you simply won’t be paid. Other rules are easier to follow. It’s easy to stay abreast of correct coding standards by connecting with the American Chiropractic Association or other coding consulting groups. It really is true that when you bill and code correctly, you make it easier for the carrier to pay your bill. Keep these tips in mind:
  • Update your coding manual annually. Note in your compliance manual every year that you have updated your coding knowledge and applied appropriate changes.
  • Make proper coding and billing a “family affair”. Educate and support key team members in learning and staying on top of coding and billing rules and changes. Compliance rules dictate that annual training is documented for all billing and coding personnel and that includes the doctor. 
  • Know that you DON’T know.  You were not anointed a coding or billing Queen or King when you received your Chiropractic Diploma. Keep the skids greased between your office and carriers by aligning with trusted advisors who can assist you with keeping your coding and billing on track and compliant. 
Firmly Follow Up
Once you’ve ensured that all the insurance relations tips noted above have been completed, and you’ve billed your appropriate services to a carrier for payment, we want your teeth to come out.  Rules and regulations apply to carriers as much as they do providers. When a clean and correct claim is presented for payment, it must be adjudicated within a set number of days. This includes payment OR pending OR denial. Know what your state insurance commissioner has to say about carrier responsibilities for claim processing. Once you know this, set up your internal system of follow up to flag unpaid claims at the appropriate time and get on the phone! Forget tracers! That’s so 1983.  Pick up the phone or get online and find out why your bill isn’t paid. And be ruthless until you get your answer. You have every right to fight on your patient’s behalf for payment of your claim. Internal accounts receivable systems that are worked, tracked and managed will ensure that you never miss timely filing deadlines and every cent that is yours will be on its way to your bank account, post haste.  Try these tips for a smooth process:
  • Set aside dedicated follow up time weekly for unpaid claims from the aging report, and for responding to denials and other reactive items that come in the mail. This often neglected area is usually the culprit in erratic cash flow.
  • Pearson’s Law states: That which is measured improves and that which is measured and reported improves exponentially. Reimbursement department team members should have metrics that are reported weekly and monthly that include number of outbound calls, dollar amounts of resubmitted claims, and other important data that helps the doctor or practice management see the follow up work being done. 
  • Be merciless in your pursuit of payment. Go to the supervisor’s supervisor’s boss’s manager if you have to. Use the insurance commissioner. Drag in the employer’s HR department or Ombudsman when you have to. Be an advocate for your patient and be sure you collect what you deserve.
Playing in the insurance sandbox is usually a “win” for chiropractic practices. Whether providing access to more patients who would not otherwise come in if they had to pay out of pocket, or providing a way to be paid what’s reasonable and customary for your services, insurance participation can enhance the business of your practice. You may choose to fully participate in all plans, to selectively identify those with whom you want to interact, or to provide a way for patients to pay you and then be reimbursed. Regardless of your decision, if you decide to work with insurance, do it with your whole heart and soul, and it will be a win-win situation for all parties involved.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P), and since 1983 she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at (855) TEAM KMC or [email protected]