Archive for August, 2009

Incorporating Other Professionals Into Your Chiropractic Practice

by Tom Necela on August 25th, 2009 in Business

Reading time: 7 – 11 minutes

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Since I am a big advocate for “working smarter, not harder” and creating profitabiltiy in your practice, several devoted blog/newsletter readers have written in asking about incorporating other professionals into your chiropractic practice.

In my own clinic, I have an assortment of the most typical practitioners chiropractors consider from the fields of acupuncture, massage and physical therapy. I have even employed an exercise physiologist, a cranio-sacral practitioner and an tanning specialist all in the name of providing my patients with the best possible care (just kidding on that last one – no fake and bake in my office!)

Additionally, I have consulted with clients who have Medical Doctors, Reiki practitioners, Naturopaths, personal trainers, nutrutitional counselors, colon hydrotherapists, holistic dentists and probably every possible specialty imaginable in conjunction with chiropractic care.

So, at this point, I have a good feel for what generally works well and what is typically a profitable venture to consider.  Before I delve into my evaluation of the specialties, let me first say that virtually any practitioner relationship can work well — if it is a good fit for your practice.  By the same token, a virtual “slam dunk” for many DC’s may be a nightmare for your practice, if your two approaches are not in sync with each other.

Note: the opinions below are in reference to employing other practitioners in your office – not of the therapies themselves.  Also, if you are a “dual” practitioner — for example, combination DC and Acupuncturist — the opinions also may not reflect the reality of your practice.

Now that you have my disclaimer, here are my thoughts on the some of the most popular practitioners that chiropractors typically havce in their office ( in alpha order):

Acupuncture:  On the PRO side, most DC’s that have worked with acupuncturists (myself included) note that patients who are willing to try acupuncture seem to benefit from it in areas where chiropractic may have not worked well.  In other words, the chronic headache patient that you can’t seem to eliminate headaches with chiropractic may benefit from acupuncture.  Post-surgical patients who have contraindications to manual therapy but for whom instrument adjusting is not doing the trick may benefit from acupuncture.  In other words, it seems to be a good fit for those patients who we may normally lose.  On the CON side, you must consider conflicting “philosophies” of care.  In Eastern Medicine, acupuncture is the dominant mode of care, so a traditionally trained acupuncturist may not necessarily want to be your “dumping ground” for problem patients.  They believe they are the first line of defense, which then may conflict with your approach.  After all, there can be only one person in the driver’s seat.  Rounding out my opinion is the NEUTRAL view of their profitability.  In the third party system, acupuncture coverage is less common than chiropractic or massage; therefore, in some parts of the country, getting paid for these services is a challenge.  Therefore, you need to be careful in the salary you are willing to pay for such a practitioner, as you still want to ensure profitability when all is said and done.

Certified Athletic Trainer / Exercise Physiologist / Personal Trainer:  PRO –For states with relatively liberal laws in terms of delegation of duties and/or rehab, any one of these professionals can be an affordable addition to your rehab department.  If you are looking to expand your practice in the direction of rehab, adding one of these practitioners can be very profitable and they require little space in which to work.  CON — navigating state laws may be difficult and you may be limited in what you can actually delegate to these assistants.  Proper documentation and set up of billing/coding may be challenging because if it is not structured correctly, all the extra money you make may go in defense of your audit.

CranioSacral Therapy:  PRO — this therapy is similar to a very gentle massage, is relaxing and can be effective for those patients who could not tolerate a traditional massage.  In many states, these therapists practice under a massage license and bill accordingly.  CON — the similarities between CST and massage may be too close for a patient to understand.  Since they frequently bill the same codes as massage therapy (and may in fact be a MT), the patient may not understand the difference between the two.  Well-trained CST’s are also challenging to find as opposed to a massage therapist who simply took a course on CST and now calls themself a practitioner.  Finally, in some areas of the country, insurance companies specifically list cranio-sacral work as investigational and will not reimburse for this service.

Dentist:  PRO — great potential referral source for TMJ, headache and PI patients with few conflicting paradigms or competition for patients.  Generally, dentists who understand chiropractic are glad to refer them appropriate patients for our care.  CON — the biggest challenge is finding a dentist who is looking to establish such a relationship. Many require large spaces for their operatories as they see many patients simulataneously. This may make overhead a concern.  If you are considering employing a dentist, you should have a large PI practice, a significant specialty practice that sees lots of headaches and TMJ patients and/or a large budget as dentists demand hefty salaries.

Massage Therapist:  PRO — massage is booming and has been growing at a double digit pace for most of this decade.  Patients love massage and it is easy to refer patients to a therapist.  A good, well trained therapist also will create new patients for the DC, as the cross-referral possibilities are strong.  Massage schools are plentiful; their graduates want to be busy and need a referral source so DC’s are considered prime employers.  Reimbursement is excellent in many parts of the country.  Many insurance plans offer massage benefits and this trend is improving. CON — Entry requirements are minimal and training levels for massage schools vary widely so maturity level of massage graduates may also vary widely.  Good hiring practices are needed to help screen for successful candidates.

Medical Doctors:  PRO — can vastly increase the scope of services rendered in your practice and in turn, create a boost in billings as well.  An MD who shares a similar approach to care can be a great convenience for your patients who need traditional medical care in addition to chiropractic.  CON — the increased services of an MD often come with a hefty price tag. A DC/MD practice must be legally and systematically structured well to avoid conflicts with Stark Laws and other regulatory problems. The “philosophies” of the MD and the DC must be very congruent or the relationship will not work.

Naturopaths / Nutritional Counseling:  Although these practitioners certainly are not the same, most DC’s seem to utilize them in a similar manner — i.e.  for nutritional (non-drug) approaches to care beyond the scope of our manual methods.  PRO — many patients have nutritional deficiencies that are quite complex and that contribute to the reasons they consult us as chiropractors.  Having a practitioner on hand who can significantly delve into this area may be of great benefit, especially to the DC who would rather focus energies on adjusting patients.  CON — Many states offer little to no reimbursement for Naturopaths or Nutritional intervention performed by non-MDs.  Scope of practice laws is also an issue with few states having regulations for Naturopaths.  Many of these practitioners also spend significant time with patients during their assessments, which means their volume is low.  Careful consideration and proper calculation should be applied to see whether reimbursements would be profitable considering salary and expenditures to have such a practitioner present.

Physical Therapists:  PRO — as above with ATC and Exercise physiologists, incorporating a PT can be an excellent addition to the rehab oriented practice.  CON — the price tag for PT’s is greater than for similarly trained practitioners such as exercise physiologists.  Philosophy may also be an issue as PT’s are trained in manual medicine and may see no need for chiropractic intervention.  The above cautions with State law regulations and Stark Law legalities both apply.  Clinics that are not busy enough could have the DC provide many of the same rehab services as a PT, without paying for the privilidge so profitability and capacity calculations need to be considered before hiring a PT.

As you can see, there probably is no “right” choice for everyone and it is important to really investigate any professional that you would have join your office.  For those interested in massage therapy, you should consider my Build a $300K Massage Program available via my website as a resource to use for developing a profitable massage practice within your chiropractic clinic.

Hope this article helps in your decision making!

Tom

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It’s Not the Economy, It’s Your Confusion!

by Tom Necela on August 18th, 2009 in Billing, Business, Collections

Reading time: 7 – 11 minutes

The year is now 75% over and most of my clients have failed to notice that their practice is “supposed to be” in a recession like the rest of the country.  If you have accepted the position that the economy is responsible for the downturn in your practice, I challenge you to read this.

In fact, I just reviewed statistics with three of the offices I consult with and here are a few of their results:  the first is on track to double his practice in 2009 will put him well into the seven figure range (with no additional marketing and one additional, non-chiropractic staff member added); the second had both May & June 2009 “best month evers” exceeding all monthly services rendered in 2008; the third cleaned up a four year collections mess and brought in an extra $37,000 in one month as a result.

Now, lest you think that this is going to turn into a long extended sales letter with lots of bragging about the fantastic results I can achieve as a result of my “secret” chiropractic practice building methods that were “accidentally” discovered in BJ’s bathroom, by channeling D.D. or some other such voodoo…I will tell you the key ingredient in each one of these success stories (and many other as well).

It is confusion – or more specifically, a lack of it.

Confusion is one of the biggest roadblocks to chiropractic practice success that I have witnessed time and again, regardless of practice size or style.

In any situation, confusion is often the chief enemy, not the economy.  In flush times, offices may get away with smaller “pockets” of confusion: systems that are ineffective, inefficient or inconsistent.  Challenging times tend to accentuate the need for clarity of purpose, efficiency of procedures and they may even sink the “confused” office, but the elements of destruction were already present.

Eliminating confusion, then, becomes a powerful method we can use to drive our practice towards the success that we long for.  Let me explain some more and give you examples:

Because of the traditional ways we have been taught to present chiropractic, we often become our own worst enemy.  If you have heard comments like “I need to think about it” or “What will my insurance cover” or “I have to discuss this with my spouse” or ‘I guess I can do that if my insurance pays” in your office, it is likely you have confused your patient in some capacity:

Here’s why: Because we have confused our patients, their only line of defense is to surrender the responsibility of the decision to their insurance company or spouse or someone else isn’t present.  After all, they don’t want to offend you, but you have not made the issues black and white enough that they can clearly give a “yes” either.  So, they delay their rejection of your care to when they are a safe distance from your office – at home.

The following is a short list of unfortunately common “mistakes of confusion” that will limit your practice growth.

Sending Conflicting Messages.  Think about it.  What are you “selling” and what is the patient buying?  If you are selling techniques and procedures, you are not on the same page with the patient.  Patients want to know what the end result benefit looks and feels like, not the many steps that it takes to get there including all possible options.  Can you make them feel well?  Can you allow them to get back to work?  Can you allow them to comfortably play with their children or grandchildren?  Answer these questions first and you have their attention.  Statistics about the degrees of curvature, phases of degeneration, or potential life altering affects of their spinal health may all be necessary to discuss, but only after you have addressed the patient’s questions and concerns.  If you fail to do this, you risk sending a conflicting message to the patient (well I am not sure he can help me with X, because he spent most of the time talking about Y) and confusion (I am not sure if A is really the problem because he kept mentioning B – maybe I need to get another opinion).  I have seen confusion kill more ROFs than any financial issues.

Not verifying insurance benefits prior to the first visit.  All elements of confusion need to be reduced or eliminated on the first visit to promote case acceptance success. For some patients, it is a big enough hurdle to just accept the idea of chiropractic. Not knowing the costs or their insurance coverage is simply too much to risk. By default, then, they will go back to the pharmacy or their MD or some safer alternative where they know what is entailed and what it costs.  Granted, it is not always easy to obtain benefits prior to the first visit, but it should be a major goal and achievable 98% of the time to avoid wasting both the doctor and the patient’s time in a visit that is essentially going to go nowhere until costs can be estimated accurately.

Not collecting at the time of service.  This problem is often related to insurance verification, but sometimes can be its own separate challenge as well.  Again, here the staff suffers from system confusion because either the benefits have not been verified or the costs per visit have not been calculated. This is especially important with patients who have co-insurances or deductibles to meet.  Instead of surprising the patient with a large balance when the insurance rolls in, staff can anticipate costs and have patients pay their portion at each visit.  This may include some tracking on your behalf; in other words, knowing what insurance companies pay for each service you offer.  It takes a little time to set up, but in terms of customer service it far exceeds telling a patient: “our average visit runs between $60-$180 and your portion should be somewhere between $20-$120.”  I have seen offices function this way

Too much talking.  In your daily visits, not enough listening also creates confusion as does too much information and detail.  In an attempt to educate the patient and establish credibility, we oftentimes introduce large roadblocks by talking more than listening.  When we talk more than the patient does, we communicate that what we have to say is more important than what they have to say.  I once observed a doctor who talked so incessantly that he frequently asked his patients the same questions two or three times in a visit.  For someone who could follow the visit in terms of the chiropractic procedures and tests going on, it was annoying to listen to this DC not listen.  For the patient, it created confusion. The patient left the visit confused about the source of her headaches (the reason she consulted the office) and now also confused about a hip problem she didn’t know she had.  My guess is after several more visits like that, she will leave to find a chiropractor who listens better and can help her understand her body’s signals.

Service Confusion.  While I certainly can attest to the benefits of providing services in addition to adjustments, some clinics create confusion by performing multiple modalities or services on a patient with no clarification or explanation of the benefits of such services to the patient.  As my practice is located Washington State, we cannot perform modalities such as electric stim or ultrasound.  Some DC’s would argue that this handicaps us, but I have seen many offices that would benefit from such a limitation.  Why?  They slap on stim pads and explain nothing of what they are doing to their patient; inevitably the day comes when the patient doesn’t have the time or the inclination to wait around for all their services and wants to skip a portion of their treatment. Educating your patient on WHY you are performing any service eliminates confusion, improves retention and solidifies the need for your treatments.  Ultimately it also creates a patient that understands what you are doing and is capable of referring others.

If you don’t think you are confusing your patients, stop a moment and reflect on whether you or your staff have ever heard questions like these: “Can I just come in twice per week instead?” “Now, what is it we are doing today?”  “Is what you are currently doing really working?”  “Is it taking too long?”  “Do I need to have the adjustment today or can I just lay on the roller table.”

If you have heard any of these, you might be confusing and complicating the process of case acceptance and/or patient retention with your systems, procedures or communication.  Simplify your life and stop making it difficult for the patient to make treatment decisions.  Re-focus your communication to be oriented around the patient’s needs, not yours.  Develop systems that serve patients by making everything crystal clear to understand.

Keep the intention on minimizing confusion and your patients will truly understand what it is you do and how things work in your office.  They may not all agree or accept what you have to offer, but you will at least communicate your services in a way that is consistent.  Consistency and clarity eliminate confusion, help retention and increase referrals. Docs are always looking for ways to do less and achieve more – clarity and lack of confusion will help get you there!

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Common Chiropractic Billing/Coding Questions From My Inbox

by Tom Necela on August 4th, 2009 in Audits, Billing, Business, Coding

Reading time: 5 – 8 minutes

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Today’s column is admittedly lighter fare as I will address the most common questions that fill my inbox on a daily basis in hopes of pointing many of you in the right direction at once.  Here they are, in no apparent order:

How Do I Learn Proper Documentation, Coding, Billing procedures or teach them to my staff? The ACA offers its members a free online tutorial for Medicare, many local Medicare carriers do the same. Some insurance companies even teach “provider workshops” covering principles of coding, billing and documentation. Admittedly I may be biased, but my seminars get excellent reviews (see seminar testimonials to read for yourself). I teach seminars all over the country and offer webinars for the homebodies. My fall schedule should be posted soon.  If your hometown is not on my list, don’t be offended, just ask!  I have several sponsors that are willing to fly me just about anywhere if they can stick their logo on your event brochure.

Is the threat of Audits something I should really worry about? That depends on how much you are willing to give back to Medicare or a commercial payer.  Medicare’s RAC program is now in force everywhere (as of August 1, 2009).  You can go to Medicare’s website and learn more about the RAC program for free. My advice: Start to “self-audit” your records. Pull a few files and see if they would pass scrutiny. Are your records legible? Are they complete? Are they compliant (Hint: Your dusty compliance binder that someone scared you into buying for $1500 isn’t enough to protect you).  If you don’t even know what an auditor would be looking for, I have also just written a non-state specific manual on “How to Prepare Your Chiropractic Practice for Recovery Audits” to assist you in the process of getting ready. (Watch your email inbox for more info on how to purchase the “pre-release” edition soon)

Do You Offer Private Consulting? Yes, I will consult with your office to get practice saving principles in your hands.  You will find that these strategies not only can save you from trouble, but will also improve your bottom line.  I can come to your office or do things via distance (phone, fax, email).  My programs are tailored to fit your practice needs and do not the usual “cookie cutter” offerings where everyone attends the same seminar to learn how to get new patients or how to practice just like me.  I focus on profitability, working smarter, billing, coding, documentation and collections strategies.

Can you give me an example of a “perfect” SOAP note that will meet medical necessity. Yes, I can but I won’t.  Why not? Because you will then copy it and use it for every single one of your patients.  The purpose of a SOAP note (or any documentation) is to communicate what is going on with your patient to someone who is not there.  While there are certain elements that should be part of every good SOAP note, it also should be a document flexible enough to change with the patient.  For example, you have three patients, all have neck pain. One is 5, one is 35 and one is 85.  Shouldn’t something about their documentation look different, even if they have the same presenting problem!  I love simplification, but there is a danger is too much simplification.  In my opinion, to give you a “perfect” SOAP note as a template for all your patients would endanger you for the reasons described above. Then, if you run into trouble with it, you will come back and blame me that my perfect SOAP wasn’t perfect when in fact it might have been just fine, had you not used the same SOAP for the last 93 visits your patient had in your office. Yes, I understand that certainly not all docs would do this, but I have no way of detecting those who would. So the simple answer, again, must be “No.”

What is the best way to transition insurance based patients to cash patients? That depends on the situation.  If you have a patient who has benefits covering 12 visits a year and you anticipate 2 more visits are necessary, this is not a billing issue but an educational one.  In other words, if after 12 visits, they don’t see the value of paying for 2 additional visits to complete their care plan, you have not done your job educating the patient or teaching them about the value of your services.  On the other hand, if you are recommending corrective care plans that far exceed insurance benefits, then you probably need to devise a working model that will allow you to affordably present the remainder of your care where insurance reimbursement is absent.  The biggest mistake I see DC’s routinely make here is not properly calculating the cost per patient visit.  In other words, they set up TOS discounts, case fees, or care plans that are just not profitable (and may may not even be legal  in their state).  When considering your fees, you should always calculate the bottom line: what it costs you, per patient, to deliver your service.  Without this calculation, you may keep the patient, but lose money providing them with care.

Can I buy some of your products on a trial basis to see if I like your ideas before I hire you? Admittedly, I don’t preach the same message as most chiropractic practice management groups, coaches or consultants.  98% of them base success on volume; I believe it is entirely possible for success (financially and personally rewarding) without high volume.  But to do so, you must learn how to properly structure your business, align your model of care, and maximize your reimbursements.  And in today’s marketplace, it makes good sense (financially and in terms of peace of mind) to protect yourself from audit exposure.  That’s my main message. If you like that line of thinking or would like to improve your practice from within on those terms, you will likely enjoy my materials.  If you have the opportunity to see me “live” you will get this message as well as many concrete ideas on how to “tweak” your practice for better performance.  That is another good way of testing to see “if we are a good fit.”

More Questions?  Use the Skribit tool to the right & get your vote counted!

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