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Orthotics
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Thursday, 25 February 2010 00:00 |
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History and Presenting Symptoms
A 45-year-old male presents with occasional, moderate pain in his left hip and groin. He has been evaluated for hernia and arthritis, with no definitive diagnosis and no successful treatment. Physical therapy with various modalities and exercises felt good, but didn’t resolve his problem. He says that he has noticed these symptoms for at least the past six years, and possibly longer. He recalls no injury to his hip or groin, and reports that he has never been active in sports. On a 100mm Visual Analog Scale, he rates his left groin pain as about 40mm. He has not identified any specific activities that consistently worsen or improve the symptoms.
Exam Findings
Vitals. This middle-aged male weighs 187 lbs, which at 5’11’’ results in a BMI of 27–he is slightly overweight, but has not established a regular exercise program because of his concern about his groin pain. He tries to eat a low-fat diet, but travels for business and is frequently unable to eat healthily. He was a pack-a-day cigarette smoker, but quit successfully four years ago. His blood pressure is 124/84 mmHg and his pulse rate is 80 bpm.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is somewhat lower than the left, with no history of fracture or surgery. His knees are well-aligned, but there is medial bowing of the left Achilles tendon, associated with calcaneal eversion. Dynamic examination of walking revealed excessive pronation of the left foot.
Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the left SI joint, the lumbosacral junction, T11/12, and the cervicothoracic junction. There is no localized tenderness in these regions, and all spinal and hip ranges of motion are full and pain-free. Provocative regional orthopedic and neurological tests are negative.
Lower extremities. Closer examination finds that the left medial arch of the foot is lower than the right when standing. When he is seated and non-weightbearing, the left arch appears equal to the right, and when he performs a toe-raise while standing, the left arch returns. Manual testing finds no significant muscle weakness in the hip abductor or adductor muscles, although the right adductor muscles are "sore" when stressed isometrically.
Imaging
AP and lateral lumbopelvic X-rays in the upright, standing position are taken while weightbearing. An obvious pelvic tilt and leg length discrepancy are noted, with the left femur head 7 mm lower. A moderate lumbar curvature (4°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left. The sacral base angle and measured lumbar lordosis are increased, but within normal limits. No loss of joint spacing or osteophyte formation is seen in the hip joints.
Clinical Impression
Moderate functional leg length discrepancy (left short leg) when standing, with associated pelvic tilt and slight lumbar curvature.
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and the lumbar, thoracic, and cervical regions, as well as soft tissue manipulation, were provided as needed. Manipulation of the left navicular, cuboid, and calcaneal bones was also performed.
Support. Flexible, custom-made stabilizing orthotics were supplied, with a pronation correction added to the left side. He had no difficulty in adapting to the orthotics.
Rehabilitation. He was shown a series of upright strengthening exercises for all hip ranges of motion, in order to speed the process of adaptation to the new alignment. After two weeks, he began a daily brisk walking program, progressing from 20 minutes to 40 minutes.
Response to Care
The spinal, pelvic, and foot adjustments were well tolerated, and the orthotics made a noticeable improvement in his postural alignment, at the feet and in the lumbopelvic region. After four weeks of adjustments (seven visits) and daily home exercises, including walking with orthotic support, he was released to a self-directed maintenance program.
Discussion
Chronic biomechanical stress can cause low-grade nociception that is difficult to track down. Had this patient been more athletically involved, it is likely that his lower extremity asymmetry would have become more obviously symptomatic. With chiropractic care and foot stabilization, he could safely initiate a walking and exercise program for health and weight control.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Friday, 25 December 2009 00:00 |
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History and Presenting Symptoms
A 25-year-old female presents with pain around her right ankle and heel. The pain has been present for about three weeks and gets worse upon weightbearing activity. She also relates running about six times per week for five miles a day, in preparation for her first half-marathon run in support of breast cancer awareness. She denies any specific injuries or direct trauma. Her medical doctor has diagnosed plantar fascitis, but she is not responding to the non-steroidal anti-inflammatory medications he prescribed.
Exam Findings
Vitals. This active young woman weighs 127 lbs. which, at 5’5’’, results in a BMI of 22; she is not overweight. She does not use tobacco products, and her blood pressure and pulse rate are within the normal range. Posture and gait. Standing postural evaluation reveals basically good alignment, but a decreased lumbar lordosis. She demonstrates bilateral calcaneal eversion, worse on the right, with a lower right arch. Gait evaluation finds obvious hyperpronation of the right foot and ankle when walking, which is accentuated when running. Chiropractic evaluation. The lumbar spine is moderately tender throughout, and she demonstrates a generalized loss of vertebral mobility, with few specific fixations. Orthopedic and neurological provocative testing of the spine and pelvis is negative. Primary complaint. Palpatory examination of the right foot elicits significant tenderness to medial/lateral squeezing of the right calcaneus. No point tenderness is noted at the insertion of the plantar fascia into the anterior aspect of the calcaneus. All right foot and ankle ranges of motion are full and pain free. Also, manual muscle testing reveals no evidence of weakness when compared to her left side.
Imaging
A lateral X-ray of the right foot demonstrates a calcaneus and talus that appear normal. There is no evidence of fracture, sclerosis or periosteal reaction.
Clinical Impression
Stress response in the right calcaneus bone, with moderate lumbar spine joint dysfunction. There is no evidence of plantar fascitis or subtalar joint malfunction.
Treatment Plan
Adjustments. Mobilization and adjustments were provided to the lumbopelvic region. The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly. Support. Flexible, stabilizing orthotics with shock-absorbing viscoelastic materials were custom made to support all three arches of each foot, in order to decrease calcaneal eversion and heel-strike shock. Rehabilitation. A foot-wheel device was recommended to improve the coordination of her foot intrinsic muscles. Once she had her orthotics, she also performed standing Achilles tendon stretches with knee straight, and then bent.
Response to Care
She was told to avoid walking as much as possible for the first week, and then only limited walking for two more weeks. She was permitted to increase her walking over the following three weeks and gradually incorporated short periods of running. At six weeks, she returned to her training program with no recurrence of heel pain, and she was released to a self-directed home stretching program after a total of 10 visits over two months.
Discussion
Stress fractures generally occur in the lower extremities, beginning as a stress response that can progress to a frank fracture. It is often said that a stress fracture is a normal response of bone to abnormal doses of stress. The rear foot or heel area of athletes is particularly susceptible to these overuse injuries, as most sports and training activities include a component of running, which places large amounts of stress on the anatomical structures of the foot and ankle. There is a higher incidence of stress fractures in young women (10:1), which is thought to be associated with their smaller bone structure, decreased lean body mass, and possible poor nutrition secondary to eating disorders.
Initial radiographs may be negative in up to 70% of patients with stress fractures. The radiographic evidence of stress fractures often lags two to three weeks behind the onset of symptoms. Typically, there will be a dense margin of sclerosis perpendicular to the trabecular meshwork and parallel to the posterior contour. Serial radiographs or radionuclide bone scans may be necessary when the initial diagnosis is questionable. In this case, the exam findings and response to treatment were clear, and no further imaging was needed.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.
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Orthotics
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Written by Dr. Paul B. Bindell, D.C.
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Sunday, 25 October 2009 00:00 |
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The curse is that insurance companies use computers to burden and audit you. The blessing is greater because the computer protects you from audits, minimizes paperwork and eliminates 95% of paper filing.
Doctors praise Electronic Health Record (EHR) computers. When audited, those doctors produced high quality SOAP records that matched the bills. The only loss was a small amount of time to deal with the audit.
On the other hand, there are horror stories from colleagues that did not have good notes. The auditors came, found the documentation did not match the billing, and demanded refunds from a few thousand to more than half a million dollars. Then the auditors filed complaints with state boards and departments of fraud. If notes do not match billing, an audit will turn your life into hell.
You have the ability to audit proof your office. It begins with fully integrated EHR management and a documentation computer that guarantees notes and billings match. The patient is signed in, the patient’s name automatically appears in the adjusting room, enters the SOAP note including the services performed, the taps and clicks are converted into a dictation quality note, and the documentation generates the charges. The patient signs out electronically, verifying the services and accepting responsibility to pay. In the event of an audit, there is a perfect match between the notes and billing, and electronic proof that the patient received the services.
Take a realistic look at your practice. Do your notes and bills match? If your answer is, "NO," then you are open to a devastating audit. For your own benefit, fix this dangerous situation before the auditor comes. Use an EHR system and bill only for documented services.
Are there times you perform a service, bill for it, but do NOT document it? An insurance auditor will use this to prove fraud, and there is nothing you can do after the fact to prove the falseness of the accusation. When using an EHR program where documentation produces the billing, there is never a bill that is not documented.
How frequently does a patient tell you something that you do not include in your records? What recommendations to patients are not in writing? Computerized SOAP documentation makes it simple, fast and easy to include these things. Using a tablet computer with handwriting recognition, it is a breeze to just jot something into the progress note and have it appear as if it was typed. Some programs integrate with Dragon Naturally Speaking, allowing you to dictate, converting your speech into typed text. The critical point is to record everything that the patient tells you, as well as to record all the advice and recommendations you gave.
A cash, pay as you go, practice does NOT protect you from audits. Although it reduces the chances of being audited, there are many cash practices that have been audited. The courts ruled that, as soon as a patient submits a receipt for services to insurance, you are held to the same standard as if you were a participating doctor accepting assignment. This means that, even in a practice where every patient pays you up front and you never send anything directly to an insurance company, the insurance company has the right to audit. Some cash practice doctors have had an extremely rude awakening, being required to refund substantial amounts, and then having to deal with departments of insurance fraud. The bottom line is that, no matter what type of practice you have, it is critical that your billing and documentation match.
Documentation extends beyond SOAP notes. Do you send letters to patients? Better EHR office management and documentation systems include templates for letters and documents, and save a copy of each in the patient’s file. Narrative reports are saved as part of the electronic record.
There should be a record of every phone call, including the date and time of the call, who was spoken to and what was said. EHR systems include phone logs in each patient file, and this phone log may save you a lot of grief. A real life example: Several years ago a mechanic came in with severe low back and leg pain. The doctor determined the patient had a disc lesion, and treated it. The patient felt relief and went home with instructions for bed rest and to return the next day. The patient did not return. The doctor called to find out what happened. The patient’s wife answered and reported that the patient felt so much better that he was outside, under his truck, replacing the transmission. The doctor entered this in the patient’s phone log. A few weeks later, the doctor received a records request from an attorney. The records with the log were sent to the attorney, and that was the end of it. The doctor learned that the patient ruptured his L5 disc while changing the transmission, but was blaming the doctor. If the log had not been maintained, the doctor would have had a nasty malpractice suit.
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Even in a practice where every patient pays you up front and you never send anything directly to an insurance company, the insurance company has the right to audit.
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Police reports, MRI or other reports, pictures, explanation of benefits (EOB’s) and other documents need to be part of the patient’s records. EHR programs include the ability to scan these things into the patient’s file, making them accessible at the touch of a button.
In an audit, it is necessary to prove that you are always aware of clinically special items about a patient. This could be a message regarding a condition (osteoporosis, gibbus formation, disc herniation, spina bifida) or to use a specific procedure. EHR programs include these notices as pop ups in the patient’s file, and the record of these pop ups can be printed easily.
 The blessing of the right EHR computer system is that it protects you from audits, saves you time in the office, and increases your income. The time to accept and use this blessing is before an auditor pays you a visit.
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Orthotics
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Written by Dr. Mark Studin DC, FASBE, DAAPM, DAAMLP
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Sunday, 25 October 2009 00:00 |
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You treat Mrs. Jones today, complete your fee slip, and your insurance staff has every document necessary to bill the claim. They have the application for benefits and/or proper claim forms from the patient, along with the correct policy numbers. The staff also has all of the completed notes/letters of necessity/results required ready as attachments to send with the claims, and you send the claim to the carrier within 48 hours of service. The insurance carrier either pays your bill in full or lets you know why they are not paying within a 30-45 day window, and you have no receivables beyond 45 days. Your accounts receivable for insurance are $0.
Have you accused me of being delusional yet?
Here’s the typical office:
You see the patient, fill out a fee slip and you give it to your front desk. They, in turn, give it to the billing staff that enters the codes into the computer. In many cases, the staff chooses the diagnosis from a list you have given them without their having a shred of education on how to accurately cross link codes. The Health Care Financing Administration (HCFA) form, or some similar form, is created and then sent to the insurance company, usually with no attachments, and you are hoping for prompt payment.
Every 30 days or so, your billing staff prints out a computer log of accounts receivable and starts to call on the delinquent ones. Historically, the staff chooses to wait 45-60 days until they start to call to collect on the claims. During this time, they let the insurance correspondences back up, even though most issues have a 30-60 day time frame in which to respond before your rights to get paid expire. Most offices do not respond in a timely fashion and that is exactly what the carriers count on.
Here are the issues:
1. You have a billing staff and most have no experience or education in collections. Usually they have no training in billing and neither do you. Collectors have to know the laws of the state that the insurance companies have to abide by.
2. Computer receivable logs do not work. Most of the staff gets through A-M in the alphabet each month, if they are lucky. The N-Z list rarely gets the attention that A-M does. Ask your staff.
3. Picking up the phone as your primary collection tool is a failed technology. If you have 20 claims generated per day, a good collector can only get 4-5 claims resolved in a day. If you take into account being put on hold, not being able to locate the file and the callbacks required, 4-5 on the average is good. That means, if you get paid on 50% of your claims without calling and you have not gotten paid on 10 claims per day, each day in practice, you fall behind 5 claims. It’s not your staff’s fault; it’s your system that doesn’t work. It will soon be your staff that doesn’t work also, because they will quit out of frustration of working in a system that is set up for failure. Verify the facts, not with your staff, but by looking for yourself…. It’s your money.
4. When you pick up the phone, you are begging and pleading with the insurance companies to get paid, and you will fail more than you will succeed. The moment you pick up the phone, you are playing the insurer’s game and they know it. This is where the laws of your state need to be utilized as leverage to get paid for services rendered.
5. You will end up treating a good portion of your patients for free. Those letters that the insurance company sends you are designed to "paper you to death." They know that you cannot handle the paper burden, and they have also profiled who does not respond to them in a timely manner. Read the back of the explanation of benefits. Most states require the carriers to print the statutes on the claim directly. Some states simply require that you know.
I was in a similar situation, and I was tired of treating patients for free. Well, not really for free. I had to pay for my staff, the supplies, the electricity, the insurance, the rent, the ink to write the notes, and I was liable for every patient I touched, so it wasn’t for free. I had to pay a lot of money to treat those patients.
First, you and your staff need to know the laws in your state. Start by calling your state’s Department of Insurance and asking them the mandated time frames for insurance companies to either pay or report to you that there is a legal delay in the claim. In New York, for instance, the carriers have 30 days to pay your personal injury claims (NYCRR 65.15(e)(2)) and, if they do not pay or notify you of a "legal" delay, they have to pay you 2% per month without the assignee (doctor) demanding interest payment (65.15 (e)(2)(h)). Most other states have similar laws.
If a carrier did not pay me within the mandated time frame, my office sent them a notice that, if they did not pay our claim, we would report them to the New York State Insurance Department and Consumer Service Bureau, and they would be fined $500 per day, per HCFA, as penalty by the State of New York under the "Prompt Pay Law" (Section 3224a of the New York State Insurance Law). We had a form letter that stated the law and it was sent to the carrier via mail with a copy of the HCFA form.
Again, most states have similar laws.
If there were 50 unpaid and unanswered claims each day, how long did it take a staff member to pull the claim, copy it, attach a delinquent letter and put it in an envelope? Each staff member could complete over 50 collection actions per day and we never fell behind, no matter the volume. This is versus the 4-5 you can get on the phone to complete a collection action. Occasionally, we did pick up the phone on larger claims, but our story was the same when we eventually got the carrier on the phone.
Your current conversation is, "I sent you the claim. Pay my bill...pleeeeeeeeeeease!!!!! Look at your statistics and see how well you are doing with that plan.
By using the laws of my state, we went from 50% collections to 90% of the fee schedules. The balance we either litigated and/or arbitrated and I have successfully gone through this process in multiple states.
You cannot beg and plead for your money. There are laws in every state to protect you and, those that understand the laws and use them get paid. The insurance companies profile you and know who begs and pleads versus those who utilize the law to rightfully get paid. The latter group gets paid with much greater ease.
You are entitled to get paid a fair fee for every service that you render.
 Dr. Mark Studin is the President of C.M.C.S. Management which offers the Lawyers Marketing Program,Family/MD Marketing Program and Compliance Auditing services. He can be contacted at www.TeachChiros.com or call 1-631-786-4253.
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Sunday, 25 October 2009 00:00 |
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History and Presenting Symptoms
A 41-year-old male presents with a history of recurring episodes of mild to moderate pain in his lower back. He states that his back pain just seems to come and go, with no specific triggering activities. He does not participate in any competitive or recreational sports, and recalls no injury or trauma to his back. He has recently been diagnosed as a borderline non-insulin dependent diabetic, and is trying to improve his diet to manage his blood sugar levels.
Exam Findings
Vitals. This heavy-set man in his early forties weighs 218 lbs, which at 5’10’’ results in a BMI of 32—he is not just overweight; he is obese. Since he reports no regular exercise, his additional weight is very likely due to excess fat mass. Although he is a non-smoker, his blood pressure and pulse rate are both elevated—144/96 mmHg and 88 bpm. His waist circumference measures 48 inches, indicating that he is carrying much of his weight around his mid-section.
Posture and gait. Standing postural evaluation finds generally good alignment throughout his pelvis and spine, but a flattened lumbar lordosis with a large abdominal load. He has bilateral knee valgus and calcaneal eversion, with pes planus and hyperpronation bilaterally. During gait, both feet demonstrate an obvious toe-out. Inspection of his shoes finds scuffing and wearing at the lateral aspect of both heels.
Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with local tenderness. Both of these segmental dysfunctions demonstrate loss of endrange mobility in all directions. Additional fixations are noted at T12/L1, T9/T10, C5/6, and C1/2. Lumbar ranges of motion are somewhat limited in all directions by his excess weight, and extension is limited to 10° by localized back pain. Neurologic testing is negative, although his deep tendon reflexes are generally sluggish. Examination of the knees and ankles finds no ligament instability, and all knee and ankle ranges of motion are full and pain-free.
Imaging
Upright, weight-bearing X-rays of the lumbar spine demonstrate loss of intervertebral disc height at L4/L5 and L5/S1, with moderate osteophyte formation at those levels. There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is noted.
Clinical Impression
Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction. There is also poor biomechanical support from the lower extremities, and his condition is exacerbated by the excess weight his skeletal structures must carry.
Treatment Plan
Adjustments. Specific chiropractic adjustments for the lumbosacral, lower thoracic, and cervical spinal regions were provided as needed.
Support. Custom-made, flexible stabilizing orthotics were provided to support the arches and decrease stress on the knees and back.
Rehabilitation. This patient was shown elastic tubing exercises to begin strengthening his spinal stabilizers and core musculature. He was also instructed to gradually initiate a daily brisk walking program to increase his metabolic rate.
Response to Care
He responded well to his spinal adjustments, and to the reasonable changes in diet that were suggested. He also adapted quickly to his orthotics, which allowed him to begin his program of brisk walking without exacerbation of back or leg pain. He was very dedicated to his home spinal stabilization program, and enjoyed showing the progress in his exercise log. After six weeks of adjustments (10 visits) and daily home exercises, he was symptom-free and had lost 17 pounds. At that point, he was released to a wellness program to oversee his continued exercise and weight loss program.
Discussion
This patient was obese, based on his BMI, and he had three of the signs of Metabolic Syndrome—waist circumference over 40", blood pressure over 130/85 mmHg, and elevated blood glucose (by report). In addition to experiencing chronic stress on his musculoskeletal system, he was also at risk of developing diabetes, cardiovascular disease, and an early death. His chiropractic care included orthotics to support his strained lower extremities, and specific exercises to improve his core stability, along with dietary recommendations. As is true with most patients, he was aware of the necessary lifestyle changes for health, but needed guidance and professional support through the initial stages.
 Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.
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