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Written by James C. Antos, D.C., DABCO
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Sunday, 25 November 2012 16:56 |
A s a chiropractor I use lumbar braces on my patients a great deal. I experience wonderful success in my therapeutic results as well as very strong financial re-imbursement, especially from Medicare. I believe that every chiropractor should be a certified DME provider for Medicare; it just makes good sense.
 In the use of good quality lumbar bracing that is approved by Medicare (the only ones I will use) it is important to document in the patient’s chart why the brace is given and its effectiveness. A physician must and should expect good results and the chart should reflect those results.
I happen to like using functional testing to establish the need for and the effectiveness of any procedure I deliver. This is especially true in lumbar bracing. The “Get up and Go” test delivers on both points. This test paints a picture of the patient’s functional status (for example: stability) that medical reviewers or even laymen can understand. There are many other ways to document but this particular test is especially effective.
In the Journal of Rehabilitation, Research, & Development¹ the authors, James C. Wall, Phd. et al., explain at length “The Timed Get up and Go Test.” Other great sources are an article in the Journal of American Geriatric Society², written by authors Podsiadlo and Richardson, as well as an article in the Arch Phys Med Rehabilitation³, courtesy of authors Mathias, Nayak, and Isaacs.
For the purposes of a chiropractor or therapist testing a patient here is how the test is conducted:
- The patient is sitting.
- The doctor/attendant instructs the patient in how to perform the “get up and go” task.
- The doctor/attendant observes the patient performing the “get up and go” task, noting the time in seconds it takes the patient to complete the task. He/she also observes other various points such as antalgia, gait, posture, stability, or others that may be observed.
The total time it takes a patient to perform the task should be 10 seconds or less. Any time over that is abnormal, with any time over 20 seconds being very significant.
Here are the instructions to the patient on how to perform the tasks of the “get up and go” test.
With the patient sitting in a chair, they are instructed to (when told to start) stand up on their own without using the arm rests. If they have to use the arm rest, note that in the chart. Once up they are to then walk about 10 steps, stop, turn around, and walk back to the chair. Once back at the chair they are to sit again. The test is over once they get to a comfortable, steady point when sitting.
During the test I look for lots of indications of an impaired patient, such as muscle weakness, balance issues, heel/toe walking, cadence, hip swing, and all the other nuances that you may observe. If the patient takes 10-20 seconds to finish the “get up and go” task, this is considered abnormal. I find this a great deal in my patient mix.
Patients that take over 20 seconds reflect a significant impairment functionally and need serious attention. I see this often as well.
Braces can be very effective in stabilizing a patient in danger of exacerbation or falling. Some braces actually help increase the strength of muscles.
The next step I take in my office brings this test to another level. If I feel that stabilizing the patient’s core or lumbopelvic spinal axis would be helpful, I fit the patient with a LSO (lumbosacral orthotic) and do the test again. Immediate improvement in performing the “get up and go” test in a shortened time or stabilizing other factors proves to me the need for the brace.
During the course of treatment I periodically check the patient’s performance level of the test. I usually see the time diminish, often to normal levels. At that point, using a small activity belt support such as a L0627 (one of the many levels of belt classifications) might be all that is needed.
This is just one way a physician or therapist can chart effectiveness and medical necessity, as well as the progress and compliance of the patient, when using a DME brace in the patient care plan. Braces can be very effective in stabilizing a patient in danger of exacerbation or falling. Some braces actually help increase the strength of muscles. Certainly braces can be a wonderful part of a care plan for a spinal patient. I want to do the very best for my patients. And I know you do too.
Consider functional testing, such as the “Get up and Go” test in your overall assessment and documentation of a spine-compromised patient. You won’t be disappointed and your results will improve.
Reference:
- Wall JC, Bell C, Campbell S, Davis J. The Timed Get-up and go Test Revisited: Measurement of the Component Tasks. Journal of Rehabilitation Research & Development. 2000 Jan;37(1):109-114.
- Podiadlo D, Richardson S. The Timed ‘Up and Go’ Test: A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of American Geriatric Society. 1991; 39:142-148.
- Mathias S, Nayak USL, Isaacs B. Balance in Elderly Pateints: the ‘Get Up and Go’ Test. Arch Phys Med Rehabil. 1986;67:387-389.
James C. Antos D.C., DABCO, Dr. Antos has been in private chiropractic practice for 34 years. He is a a lecturer for Florida State License renewal on behalf of the Florida Chiropractic Association in the years of 2011 and 2012, teaching the the topic"DME and Lumbar Bracing". He can be reached by phone at 386-212-0007, or visit his website at www.antosdmebrace.com
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Written by Paul S. Inselman, DC
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Tuesday, 23 October 2012 18:11 |
L et’s face it; there is much uncertainty that plagues not only our profession, but the world economies at large. Add into the mix $65 co-pays, decreasing insurance reimbursement schedules and the new Obama-Care Health Law, and it’s no wonder chiropractors are losing sleep.
 This article will walk you through the uncertain economic maze and give you clear-cut strategies you can utilize so, no matter what happens to insurance, you will be in a profitable position to deliver great chiropractic care to your patients.
In this economy it is imperative that your attention turns to “the business of chiropractic”. Before you hang me in effigy, please understand that running a business and turning a profit is not bad or evil. If you want to do pro-bono work then by all means do so. Remember that your electric bill, rent bill and every other bill you have will come due each and every month. If you do not have the funds to pay your bills, you will go out of business and not be able to take care of anybody. So, like it or not, you are going to be forced to at least earn enough money to pay your bills. Since you have to earn money anyway, why not maximize your return on investment and earn as much as you ethically and legally can?
The first key to running a successful business is to understand basic business principals. You should be able to generate and interpret the following reports: profit and loss statement, balance sheet, cash disbursements book, and the creation of budgets. If you are not familiar with these accounting reports then my suggestion is to enroll in some basic business classes to acquire these needed skills. Another good way to become familiar with these reports is by using accounting software. There are several excellent programs that will create the reports for you, but as my father always used to tell me, “Numbers must mean something;” therefore, you must be able to interpret what the numbers mean.
The next recommendation is to keep meaningful statistics on your practice. If you fail to keep good records, how can you possibly determine if your marketing efforts are working? I recommend that you keep monthly and year-to-date stats of the following: month worked, days worked, new patients, office visits, avg. people per day, services rendered, income collected, PVA, average income per visit, and accounts receivable.
Now that we have the foundation for running a business we need to turn our focus to creating a practice that will run in an insurance or non-insurance environment. This step is imperative for our profession’s continued success. In my opinion, the handwriting on the wall regarding insurance reimbursement is not looking too good. Let me cite a couple of insurance examples to make my point:
In October, 2011 the North Carolina Bar Association Health Benefits Trust started charging a $65 co-payment for specialists on their Blue Options Plan 4 insurance plan.
In May, 2013 Florida passed a new No-fault law. The new bill provides strict and rather biased definitions of what constitutes medical treatments and covered injuries. Accident victims now must seek medical treatment within a narrow 14-day window from the accident and only from specified licensed medical physicians. Acceptable treatment providers include emergency services determined by a physician, osteopath, dentist, physician’s assistant or registered nurse practitioner. Chiropractor visits are limited to $2,500 and can only be sought after a referral from an acceptable health care provider.
Remember, as one state changes, other states follow suit. How far behind do you think your state is? Do you know what the definition of a $65 co-payment is? The answer: A CASH PRACTICE.
What I have been teaching my clients and what I hope to teach you, the reader, in this article is how to insulate yourself and your practice against these insurance changes that are coming very quickly down the pike.
If you fail to keep good records how can you possibly determine if your marketing efforts are working?
All consumers will pay for something that we feel has value. If we sincerely believe that our purchase will help enrich our life, we will spend money on it. Our patients and potential new patients are no different. If your care will solve their problem and enrich their lives they will be able to find the money to afford your care. When a patient tells you that they can’t afford your service, what they are really telling you is, “YOU did not create enough value to allow me to give you my money.”
Let me give you an example. When was the last time that a homeless, destitute person came to your office seeking care? 99.9% of you will answer never. The other .1% will answer maybe once in my whole practice career. Why don’t homeless, destitute people come to our offices seeking care? The answer is because they know that they cannot afford our service. Any patient that walks into your office knows that they will incur an expense of some kind. Whether that expense is in the form of a co-payment, full payment, premium increase, etc., they know and understand that payment of some kind will be required. Once they walk through your doors it is up to you to create value to enable them to want to stay and have you fix their problem. If you master the skill of creating value for your patients, it will not matter to you if insurance pays 0% or 100% or anything in-between. Your patients will know and understand and want to pay you for your service.
You may utilize the following checklist to help insulate yourself if insurance reimbursement goes away:
- Start running a business instead of just a practice
- Make sure that you are performing a proper consultation and report of findings (see the article that I wrote in The American Chiropractor Volume 39, Number 8, August 2012 pages 64-68)
- Create a minimum of five and preferably ten independent strategic-based marketing campaigns
- Make sure that your procedures were created and or revamped to reflect the present economy
- Create niche-oriented, cash-based ancillary procedures
- If you are unable to improve your practice on your own, seek professional help
- Make sure that you are implementing habits of excellence in your personal and professional life
- Create written goals with meaningful action steps
- Track everything that you do to evaluate if it is working or not working
- Don’t just treat a condition, treat people’s problems and become their problem solver
- Create an emergency fund with a minimum of one year’s practice and personal expenses
- Do not use a credit card unless you are able to pay the balance in full each month
- Be willing to invest and spend money to make money
- Focus on what you want, not on what you do not want
The final piece to the puzzle is to be prepared. All of healthcare, including chiropractic, is going to go through some tremendous changes in the next few years. Living in fear or denial will not help you or your practice. If you believe that insurance reimbursement is going to deteriorate further, you must begin to do things in your practice differently NOW. When change is inevitable it is imperative that you institute and adopt the changes as quickly as possible. Proactively making necessary changes instead of reacting to change will allow you to stay ahead of the curve and remain profitable. If you don’t know where to begin or what to do, ask a colleague who has achieved what you want to achieve. If you don’t, have a friend or colleague who can help you seek professional help from a practice management firm.
Dr. Paul S. Inselman, President of Inselmancoaching, is an expert at teaching chiropractors how to build honest, ethical, integrity-based practices based on sound business principles. From 2008-2012 his clients practices grew an average rate of 145% while the general profession was down 28%. His 26 years of clinical experience coupled with 10 years of professional coaching has allowed him to help hundreds of chiropractors throughout the nation. He can be reached at 1-888-201-0567 or
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Written by Kirk Lee, D.C.
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Tuesday, 01 May 2012 17:10 |
E ven with everything we do in the evaluation process of our patients, sometimes outside forces like activities of daily living, job, family and financial stress can complicate the presenting vertebral subluxation complexes and its resulting signs and symptoms. Sometimes even the littlest postural changes can affect our outcomes.
 When we conduct our evaluation and management of a patient, we benefit from a thorough history based on a review of the patient’s case history or other admitting information that we request the patient to fill out. This is followed with a one-on-one consultation to review the case history where we ask additional questions to further assist our decision making. This history covers the requirements of chief complaint, history of present illness, review of the symptoms and past family and social history.
Then we perform the appropriate examination that we feel clinically is necessary to provide us with needed information in evaluating posture, ranges of motion, functional movement patterns, palpation findings, orthopedic and neurological findings. We also have to take into consideration that documented information is required to meet the billing requirements for the level of E&M that we feel is appropriate for billing purposes.
Using a digital foot scanner to evaluate the three arches of the feet to establish the patient’s pronation index will determine if he/she may benefit from the recommendations of stabilizing orthotics. Evaluation of the patient’s gait cycle using a system of analysis provides us a baseline of the different phases of the gait cycle to compare both the right and left sides. If the patient is a runner, we should conduct the analysis in both the walking and running phases. We may go as far as asking our patients about activities of daily living or a description of their job duties. How much information you feel you need to obtain through the evaluation and management process to help you with your level of medical decision making is totally based on your clinical judgment. Just keep in mind that you must always obtain enough patient data to support the level of E&M for which you are billing.
Ms. W. is a 28-year-old runner who runs an average of five miles, four to five times a week. She has been under our office’s care for the majority of her adult life. She first consulted our office with complaints of low back pain and chronic Iliotibial Band Syndrome. Following a treatment plan of chiropractic adjustments, core strengthening exercises, and stabilizing orthotics, Ms.W. responded very well and now enjoys the benefits of a wellness lifestyle. Recently, she began experiencing pain in the right shoulder area which was about three to four weeks in duration. Pain is more pronounced on the posterior side. She describes the pain as a 5-6 on a scale of 10. She also notes it develops during her run and is usually gone the following morning.
There is no history of trauma or other known reasons for the pain. We conducted a re-evaluation of Ms. W., which included a new digital foot scan (it had been three years since her last pair of new stabilizing orthotics) and a new gait analysis for both walking and running since the pain comes on while she is running. Nothing major is derived from our re-evaluation, but we begin adjusting the right shoulder. After several weeks of treatment, no noticeable changes have been noticed within the shoulder. It has improved slightly, but the pain still flares up each time she runs.
I asked her how long she had been carrying the water bottle while she was running. One evening after work I drove over to see my good friend Dr. Knight, who practices 12 miles west of me, for an adjustment. I notice my patient, Ms W., is out ahead of me on this country road. Realizing it is her, I stay some distance back to see if I notice any asymmetry in her gait that we did not pick up on the treadmill. What I did notice was how she was flaring her right elbow and how she was holding it in an abducted posture. I then noticed the culprit that was causing this abnormal posturing. It was a water bottle! When I finally pulled up beside her I asked how her shoulder was feeling and she mentioned it had been getting tighter and sorer over the last mile.
I asked her how long she had been carrying the water bottle while she was running. She told me she had been doing it for about a month since her belt she normally wore that carried her water had broken. As she was explaining it to me you could see a quizzical look come over her face. She asked me, “Do you think my shoulder pain is caused from me carrying the water bottle?” I smiled and said, “Let me have your bottle, finish your run and I will see you tomorrow!”
We all know that ADLs and prolonged postures can be major causes that slow the healing powers of the body. As our patients enjoy the great benefits of a chiropractic lifestyle, through the many services that we can provide them, we must always consider the not so obvious when it comes to our patients!
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.
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Written by Claude Cote
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Tuesday, 01 May 2012 17:04 |
T here is no doubt that obtaining $44,000.00 from the government is very enticing. In this hard economy, who would say “No” to such a gift? A gift? Well, not exactly. If you are interested in Electronic Health Record software programs, you already know that doctors will need to meet all the necessary meaningful use objectives in order to receive any incentive payments. On the Center of Medicare and Medicaid Service (CMS) website ( www.cms.gov), there is a section called "Attestation".
 Under that section, the CMS answers a few potential questions you may have. One of them is: "Will CMS conduct audits?" The answer is clear: "Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program may potentially be subject to an audit." And then they explain how to be prepared for an audit. In the best case scenario, where you do your very best to meet all the conditions, where you keep your documentation at the best of your knowledge and where you keep your office legally crystal clear, an audit is never fun.
And if the auditor finds something wrong, you are the responsible person, not your software provider. You might not be very excited to do all the necessary work to meet all the meaningful use objectives and you probably do not wish to get an audit either. If this is the case, why don't you create and implement your own stimulus plan? If you decide to compete with the government by creating your own stimulus plan, not only will you not have the hassle of implementing a fully certified software and showing all the meaningful use objectives that the government is imposing, but you may be able to receive substantially more than $44,000.00 over a 5-year period and have much more free time for yourself and your family. One size does not fit all. Many chiropractic doctors do not want to do their stimulus certification and do not want to go through unnecessary audits. Right now, it is only a very small percentage of eligible providers who are registered to do their stimulus certification. But don’t worry, there are some good alternatives for all other doctors. There are many recipes to create your own stimulus package. Planning, organization and perseverance are the keys to success.
Planning
In all new projects, good planning is mandatory. What do you want to achieve? How much revenue increase would you like to get? How much growth are you looking for? The $44,000.00 payment the government is offering over 5 years represents only 3.5 adjustments per week (at $50.00 each). This is not much. Don’t you think you may increase your office by 4 visits per week if you are serious about it? I am sure you can. Let’s say, as an example, that you see 100 patients per week. You may set up a goal where you will see an average of 125 patients per week within 3 months from now. Let’s beat the stimulus package by 21 visits per week. Is this realistic? Absolutely.
Not only are these achievable numbers but this will probably be easier than you think to achieve. As a second goal, would you like to spend more time with your patients on each visit? And, as a last goal, recoup 4 hours per week and spend that time with your family. This does not seem to make sense, right? How can you see 25% more patient visits, spend more time with your family and spend more time with your patients? The answer is Organization. By the way, 21 visits per week at $50.00 each, 50 weeks per year for 5 years amounts to $262,500.00. This is almost 6 times the entire government stimulus package.
Organizing
You don’t need to use a certified software program to implement all the meaningful use objectives. In many chiropractic offices, organization is the weakest part of the entire business. This is where information technology will be your best friend. The best and easiest patient growth is through the actual active patients referral. If you spend less time in administrative tasks and use that valuable time educating your patients, you will definitely increase referrals. Increasing referrals means more patient visits. A full automated system will reduce your administrative tasks, will speed up all your processes and will provide, at a glance, all the necessary information needed to provide the greatest care to your patients, in less time.
Searching for a paper patient health file does not help any patient in his care. If the system you are presently using has a good statistic module, use it. Find out how many patients have left your office without any other appointment and have a list of who they are. Are they really done with their care or are they just on the edge of dropping chiropractic? These are only a few very simple examples of how good organization, using great information technology, will make it easy for you to reach your goal.
Persevering
There is no use putting anything new in place if you do not persevere. If you implement a new procedure, believe in it and be patient. Success comes over time. Just keep doing it and you will see results. Perseverance is probably the hardest thing to achieve. Implementing something new takes you out of your comfort zone. If you keep persevering, your new procedures will eventually become your comfort zone.
This is a brief description of how to create your own stimulus package and how to succeed with it. You don’t need to use a certified software program to implement all the meaningful use objectives. As an example, you can record your patient smoking status in almost any software program if you think this information is useful to treat and help your patients.
Creating your own stimulus package may have many advantages over the government incentive program. You may be able to generate much more income, without having to go through the CMS registration process, or through any CMS audit, etc. As far as health benefit for the patients, you may exceed the government requirements if you want to. It’s your call! Claude Cote is an expert in EHR systems, insurance billing and chiropractic clinic management for 22 years. He has installed EHR system in 18 countries over 5 continents and nationwide in USA. He is the President and Founder of Platinum System C.R. Corp (www.platinumsystem.com). For comments or questions, please email to
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Written by TAC Staff
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Tuesday, 01 May 2012 03:05 |
After 34 years of consistent service to the chiropractic profession through her work here at the magazine, on March 29th, 2012, TAC Editor Jean Marie Irelan Busch made the transition leaving us with the honor of carrying on her legacy.
Jean, or “Jeanie” as she was called by friends and loved ones, was the loving wife of the founding publisher, Dr. Richard E. Busch, Jr. They were married 45 years, and she is survived by her six children, 14 grandchildren, and her husband. Several of her children and grandchildren continue to work at the magazine that Jeanie helped found.
 Jeanie graduated from South Whitley High School, achieving the high scholastic rank of Salutatorian of her class and went on to graduate from Indiana University in 1966 with a Bachelor of Arts degree in Grammar and Theater. While at Indiana University Jeanie was a member of the Delta Gamma Sorority, was captain of the pom pom cheerleaders, taught for the National Cheerleaders Association, and was on various Indiana University steering committees, including Little 500 etc. and the I.U. Foundation. Many who have known Jeanie remember her boisterous laugh, beautiful smile, positive love of life and comforting, silent strength that those around her could sense whenever she was present.
Upon graduation from college, she traveled to Davenport, Iowa to support her husband Richard's pursuit of his chiropractic degree at Palmer College. While there, Jeanie taught English to students at Sudlow High School. Jeanie didn't teach school long, however, because her first child, Tracy, was soon conceived.
Jeanie returned to Fort Wayne, Indiana following the graduation of her husband from Palmer College. Before her husband, the now Dr. Busch, established the Busch Clinics, Jeanie worked as a C.A. with him at the Goeble Chiropractic Clinic in Fort Wayne, Indiana. This only lasted 2 weeks while Dr. Goeble was on vacation, and then Jeanie was blessed with another child on the way. Their first son, Rick, now Dr. Richard E. Busch III, furthered the Busch chiropractic tradition. Jeanie came on strong as a leading homemaker and mother fostering four more children: Tunde, Jaclyn, Joseph and James. Joseph, Jaclyn and Tracy are also graduates of Indiana University, with Joe furthering his education at the National Chiropractic College. Her children continue to present strong leadership for The American Chiropractor Magazine, a trait learned from their Mother.
 Jeanie was also active in civic and sorority matters. In Fort Wayne, Indiana, Jeanie was active in Career Day for kids and established the category Homemaker, which was previously missing from the choices. Also, at one time she was the leader of four Brownie Troops. She was instrumental in leadership and giving her time to help her family and others with continued support for her husband in his many endeavors.
 In 1978, Jeanie was called on to sell advertising in The American Chiropractor. She did so under the pseudonym Tracy Leigh. She sold an ad over the telephone on her first call! She was also one of the original editors for The American Chiropractor Magazine, with a meticulous eye for grammatical mistakes and a passion for commas, as her family liked to joke. When not editing, she was also selling advertising to many of the same companies that have become prominent supporters of the profession. From that point in 1978, Jeanie was never far away from all aspects of The American Chiropractor Magazine. When not directly involved in the delivery of the content, you could find her working on some other aspect of the magazine.
The traits that were most respected by those that knew Jeanie were her compassionate heart and tireless work ethic. Those who were around her felt blessed to have shared in her time, and those who loved her will carry her memory in their hearts.
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