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Insurance Company Retrospective Audit Tactics: Be prepared or give your money back
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Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Friday, 25 January 2013 01:21
I
f you accept insurance, you are a target of the insurance carriers on many levels. First, you cannot be "Pollyannaish" and think that because you are a "healer" or help people on so many levels you are deserving of the fees you get. That is not part of the equation. Your patient has a contract with his/her insurance company and your claims trigger provisions in his/her contract for you to get paid. Nothing more or less.
 
moneyinpocketDue to the fact that this is about contracts and contract law, there are many ways to interpret the language within those contracts. Lawyers hired by the insurance companies have made a "cottage industry" out of using the courts to redefine the agreements to secure additional profits. The carriers have been so successful that they have retained some of the best firms nationally to ensure increasing profits. The carriers are now utilizing "old" technology created for their benefit with a twist to further increase their bottom line at your expense: IMEs and Peer Reviews. 
 
The IME or independent medical examination and peer review processes are necessary and integral steps in maintaining a system of checks and balances in health care billing in order to prevent unnecessary care. Over the last two decades, the system has evolved to where too many doctors who are hired by the carriers through an IME company (middle man) or directly by the carriers are not performing examinations that are remotely close to independent. Two decades ago, some of the facts reported were not accurate, leading to desired conclusions. Today, it is a rarity to see the facts represented accurately, based upon this author's 31 years in the industry reviewing IMEs and peer review reports nationally and polling treating doctors and lawyers from coast to coast.
 
Over the years, it has been my experience that too many IME companies have handed doctors completed reports, mandated diagnoses, misquoted research and/or given strict orders regarding the scope of care permitted, all prior to the examination. In almost every instance I have encountered, the carrier or IME company has offered to send the doctor more cases if he/she works with them to reach a desired conclusion, whatever that may be.
 
This is one of those scenarios where you need to be ready. This is also where the 5 P's (proper planning prevent poor performance) come into full effect and you have to ensure that your documentation infrastructure, knowledge base and credentials are strong enough to meet the challenges of today's marketplace. Basically, if you want to keep your hard-earned money rather than allow a predatory insurance carrier to, in essence, "steal your money" on what could be considered a technicality, misstating the facts or errors of omissions, then you must be prepared.
 
As a profession, we are not prepared to meet the challenges in today's marketplace to ensure that we get to keep well-deserved fees paid for honest and ethical services delivered. I have been witnessing that fact for almost a decade while working with and teaching doctors nationally. We are simply not prepared as an industry to compete with the insurance industry...yet! 
 
A modest sampling of the profession in early 2012 revealed the following: 
  • 95% of patients get IME denials (the majority of responses)
  • 73.6% of doctors give no directions to their patients going for IMEs
  • 76% of doctors (respondents) NEVER read the research behind the denials 
Fact: Right now, the carriers are ordering IMEs and peer reviews, which is nothing new. HOWEVER, based upon the independent medical examiner's or peer reviewer's often improper results, the carriers are demanding repayment of claims already paid to you and hiding behind the third party reports (IMEs and peer reviews). We (field doctors) can all agree that MANY of those reports are a work of either fiction, partial truths or outward fabrication of the history, clinical findings or test results and treatments rendered to reach a desired conclusion of non-necessity.

October  08, 2012                                    
                                                          Auto Claims
                                                          P.O. Box 10000
                                                          Atlanta, GA 3000-0000
RE: Claim Number:
        Date of Loss:                               July 7,2011
        Our Insured:
        Patient Name:
        Policy Number:
 
To whom it may concern:
 
Our policy provides coverage for charges incurred for reasonable and necessary medical expenses. An independent medical examiner reviewed the treatment bills, records and rendored his medical opinion that some of the services rendered were not reasonable and medically necessary.
 
Based on the examiner's consultation and review and all other information known to date, All Farm Insurance Company will be unable to consider the medical charges in question as they have been deemed not medically necessary.
 
AllFarm Insurance Company has previously made payments to your facility after September 9,2011. The independent medical examiner deemed any treatment past this date not related, reasonable or medically necesary to the motor vehicle accident  that occured on July 7, 2011. At this time, we are requesting reimbursement for all payments made to your facility after September 9, 2011 payable to AllFarm Insurance Companye as payments were issued in error for services not reasonable and medically necesary.
 
Please forward reimbursement with the claim number printed on the attachement to :
AllFarm Insurance Company
PO BOX 10000
Atlanta, GA 00000
 
Should  you have any questions, please contact me at the number below.
 
Sincerely,
 
AllFarm Insurance Mutual Automobile Company
 
One doctor on the east coast just received the above form letter.

AllFarm Insurance Company contends that these payments were made in error based upon the IME doctor's report. That is not true. AllFarm Insurance Company found a method to turn the "hands of time" backwards and utilized a loophole in the ability to take money away from the doctor to realize a windfall profit...at our expense. When the treating doctor examined the IME doctor's report, it was fraught with a distorted history, omissions of positive test results and improperly reporting that a complete physical examination was performed when the patient and a witness in the room verified that many of the negative reported tests were never performed.

Solution: The ONLY solution is to be able to effectively rebut the IMEs and peer review reports. The doctor who received this acknowledged that he must fight this in order to keep his money and to ensure that he doesn't continually fall prey to AllFarm Insurance Company as an easy target in the future. He also realized that in order to fight this request to repay the carrier that he has to be credentialed in the subject matter(s) in contention. In other words, if the carrier is denying care based upon the MRI results, then the doctor must have credentials in MRI interpretation to understand and be able to refute the conclusions. A complete record must also be maintained with appropriate re-evaluations every 30-45 days as prescribed by the Medicare standard, which is followed by most carriers nationally. In almost every case where the IME or peer review rebuttal was overturned, the doctor was credentialed through post-doctoral education (CE courses) in MRI, accident reconstruction, neurology, orthopedics, biomechanics, triaging the injured, sports injuries, etc. The credentials needed should reflect the type of practice you have.

Recently (October 2012), a doctor from Florida told me that as soon as he accurately rebutted a peer review denial based upon the facts of the case, citing the actual facts of the research considered by the peer reviewer, while removing any emotion in the rebuttal, the carrier instantly reversed their decision and authorized more care than he requested. They were afraid that he was going to follow through with his promise (not threats) to expose the illegalities of the carrier's hired IME hand to the licensure board and state's attorney general. The carriers are acutely aware of the issues and are concerned that this will become public and cost them. This doctor, in spite of the carrier reversing their decision, will still be going after the peer reviewer (DC) who falsified her report. These doctors need to be taken out of the system and deserve to have their licenses considered by the states for their actions to make money at the expense of the patients that are being hurt. That can only be done with rebuttals that are factual and by utilizing the laws within your state to ensure we all, treating doctor and independent examiner alike, adhere to the same practice and reporting standards. Although third party doctors have different "duty of care" standards in certain states than treating doctors, we all have the same licensure requirement to be factual in our reporting. The lack thereof constitutes both licensure infractions and possible negative legal implications of fraud.

As of now, there are very few doctors nationally that are successfully overturning negative improper IMEs. This is because most doctors simply do not understand the process. To learn more on how to do a proper rebuttal, Google "IME rebuttal" and get educated on how to be successful in defending your practice, your reputation and your money.

In addition, you must, must, must get credentialed. If you have been sitting on the fence, now is the time. MRI spine interpretation has become a critical component to the denials because the carriers’ hired doctors are often "spinning the facts" in the results that have direct impact on the necessity of your care. To be qualified in refuting these issues, get credentialed. Do a Google search for "MRI spine interpretation." The same applies at every level of your practice.

They're coming...ARE YOU PREPARED?

 
CMS Releases Meaningful Use Stage 2 Requirements
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Written by Steven J. Kraus, DC, DIBCN, CCSP, FASA, FICC   
Thursday, 24 January 2013 23:43
What it Means if you’re already using EHR software…and What It Means if you’re Planning to start This Year

C
MS recently released its final rules for Stage 2 Meaningful Use under the American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act.

At more than 600 pages, the rules are extremely detailed. Initial reactions are fairly positive, and it appears that CMS took into account the comments provided on the proposed rules by groups like the ACA and individual providers.

Here are 9 key takeaways from the newly released rules:

1. Requirement of Stage 2 Meaningful Use Criteria Delayed
meaningfulusechart2Under the proposed rules, providers were to progress to Stage 2 Meaningful Use criteria after two program years of meeting Stage 1 criteria. For example, Medicare providers who first demonstrated Meaningful Use in 2011 would need to meet Stage 2 criteria in 2013. CMS has now delayed the onset of Stage 2 criteria so that the earliest a provider would have to demonstrate Stage 2 criteria is 2014.

Note: Providers who were early demonstrators of Meaningful Use in 2011 will now meet three consecutive years of Stage 1 criteria before advancing to the Stage 2 criteria in 2014. All other providers would meet two years of Meaningful Use under the Stage 1 criteria before advancing to the Stage 2 criteria in their third year.

2. Three-month EHR Reporting Period for Stage 2 in 2014 Only
Those who completed their first year of Meaningful Use in 2011 or 2012 will only need to complete 90 days of Stage 2 Meaningful Use in 2014.

Note: This 90-day Stage 2 timeframe is ONLY for those who successfully demonstrated Meaningful Use in 2011. Then, in 2015, these providers must complete a full year of Meaningful Use. Those who begin Stage 1 Meaningful Use in 2013 will complete their first year of Stage 2 in 2015 and will be required to do so for the entire year. 

 
This Stage 2 90-day timeframe is separate from the first-year Stage 1 90-day timeframe. All providers who begin Stage 1―no matter what the year―will only have to complete 90 days of Stage 1 Meaningful Use their first year.

It should be noted that while Meaningful Use only needs to be demonstrated for three months, you still have the full 12 months to accrue Medicare-eligible allowed submitted charges to maximize your incentive amount.

3. Stage 2 Retains Core and Menu-set Criteria Structure for Meaningful Use Objectives
Although some Stage 1 objectives were combined or eliminated, most of the Stage 1 criteria continue in Stage 2, and some menu-set criteria have become core objectives under Stage 2. For some Stage 2 objectives, the threshold percentages that providers must meet for the objective have been raised.

4. Stage 2 Criteria Consists of 20 Objectives
To demonstrate Meaningful Use under Stage 2 criteria, providers must meet 17 core objectives and three menu objectives, for a total of 20 objectives. For the menu objectives, providers must select three items from a list of six options.

5. Core and Menu-set Criteria for Stage 2 Meaningful Use
Physicians must report on most all 17 core objectives:
  1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders.
  2. Generate and transmit permissible prescriptions electronically (eRx). 
  3. Record demographic information. 
  4. Record and chart changes in vital signs. 
  5. Record smoking status for patients 13 years old or older. 
  6. Use clinical decision support to improve performance on high-priority health conditions. 
  7. Provide patients the ability to view online, download and transmit their health information.  
  8. Provide clinical summaries for patients for each office visit. 
  9. Protect electronic health information created or maintained by the Certified EHR Technology.  
  10. Incorporate clinical lab-test results into Certified EHR Technology.  
  11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. 
  12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care. 
  13. Use certified EHR technology to identify patient-specific education resources.  
  14. Perform medication reconciliation. 
  15. Provide summary of care record for each transition of care or referral. 
  16. Submit electronic data to immunization registries.  
  17. Use secure electronic messaging to communicate with patients on relevant health information. 
checklist8Physicians must report on three of six Menu-Set Objectives:
  1. Submit electronic syndromic surveillance data to public health agencies.  
  2. Record electronic notes in patient records.  
  3. Make imaging results accessible through CEHRT. 
  4. Record patient family health history.  
  5. Identify and report cancer cases to a state cancer registry. 
  6. Identify and report specific cases to a specialized registry (other than a cancer registry).
 6. Clinical Quality Measures (CQMs)
All providers are required to report on CQMs in order to demonstrate Meaningful Use. Beginning in 2014, all providers—regardless of their stage of Meaningful Use—will report on CQMs in the same way.
 
Providers must report on nine of 64 total CQMs. In addition, all providers must select CQMs from at least three of the six key healthcare policy domains recommended by the Department of Health and Human Services’ National Quality Strategy, which include:
  • Patient and Family Engagement
  • Patient Safety
  • Care Coordination
  • Population and Public Health
  • Efficient Use of Healthcare Resources
  • Clinical Processes/Effectiveness 
7.  Patient Viewing, Downloading and Transmitting Health Information
One of the most controversial rules has to do with providing patients with the ability to view, download and transmit their health information. As such, providers must move forward with a patient portal, such as a PHR like Microsoft HealthVault or an actual portal to their EHR. 
 
This is a significant change from Stage 1, and it will take a significant effort to educate patients and get them to initiate the exchange. In the final rule, CMS lowered the threshold to 5% and added a “broadband exclusion” for rural areas with limited broadband access.
 
Because secure messaging has to be initiated by patients, providers will be challenged to educate patients on the availability of secure messaging as a communication option, and it remains to be seen how feasible that will be. In short, it is feasible but may be a challenge for DCs who are less technically savvy.
 
8.  Health Information Exchange between EHR Vendors and Organizations
With the goal of furthering interoperability, the proposed rule sought to ensure that providers were exchanging health data with users of other EHR vendor systems and with other organizations.  
 
CMS will require providers to conduct one or more successful data-exchange tests with a “CMS designated test EHR” during the EHR-reporting period. According to CMS, the intent of that proposed rule is to foster electronic exchange outside established vendor and organization networks. 
 
In the final rule, only one demonstration of this cross-vendor organizational capability is required. This will be a one-time test for the whole year and should be an easy criterion to perform and cross off to achieve compliance for getting the incentive.
 
9. Secure Messaging with Patients
One Stage 2 core objective is to use secure electronic messaging in order to communicate with patients on relevant health information. A secure message must be sent using the electronic messaging function of Certified EHR software to at least 5% of unique patients you see during the reporting period.
 
The Incentive: Deadlines and Rewards
If you have not yet started Meaningful Use, the most you can now receive is $39,000 (from a previous high of $44,000). But you must begin Meaningful Use by October 2013 to collect up to $39,000.
 
If you start after October 4, 2013 and before October 3, 2014, you can qualify for up to $24,000.
If you do not start by October 3, 2014, you will get zero dollars.
 
Many DCs lament that they need to make more money. Compliance with this program will take several hours of work—most of which can be performed by staff—and  DCs can collect up to $39,000 per provider over the next five years, with $15,000 allowed for just 90 days of effort in 2013 for first-time meaningful users.
 
Ninety percent of Meaningful Use criteria can be performed by staff. More than 4,896 DCs are scheduled to complete attestation for 2012 with over 1485 already successfully paid for  Meaningful Use. Most of those DCs received the maximum amount of $18,000 for their first year of Meaningful Use. This is a golden opportunity to inject more than $2 billion into our profession.
 
Take advantage of something all healthcare providers are implementing anyways: EHR will soon be a standard of practice. You can do it with training, determination, and simply taking your first step.  Choose to do it now and get paid for it, rather than being forced to do it later with no incentive money. You can be a leader or a follower.

Steven J. Kraus, DC, DIBCN, CCSP, FASA, FICC, is Founder and CEO of Future Health, the nation’s #1 provider of chiropractic-specific EHR/practice management software. He is an acknowledged expert in Health IT, including EHR (electronic health records) and the up-to-$44,000 ARRA incentive program to implement EHR.

Dr. Kraus has served―and continues to serve―on numerous committees and boards, including:
  • ACA Computer & Technology Advisory
  • ACA Legislative Commission
  • ACA Quality Assurance and Accountability Committee
He lectures to state associations and at industry events regarding EHR and the relationship to documentation, and he presents monthly webinars on how EHR usage will impact doctors of chiropractic. For more information, visit www.FHeConnect.com/1074 or call Toll Free 1-888-919-9919, ext. 652.
 
 
In Memoriam: Kirk Lee, D.C. (1957-2012)
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Written by TAC Staff   
Sunday, 25 November 2012 21:31
"Make a positive impact on each person you interact with daily."

T
hat is a difficult task, but it is one that the late Kirk Lee, DC, accomplished with grace and poise. Dr. Lee will be remembered for more than just his work in the chiropractic profession—which is significant—but also for his positivity that lit up every room he entered. His presence and cheerful attitude could make a bad day turn good and a good day even better. He was more than a chiropractor, an instructor and a writer; he was a loving husband, doting father, proud grandfather and beloved friend. Dr. Lee will be missed by all who knew him, and his legacy of practicing kindness will live on through those who had the pleasure of knowing him.
 
Gentle Giant in Chiropractic
kirkleememoriamDr. Lee was known for his chiropractic expertise in the field of sports injury. He wrote countless articles on the topic, especially those related to running. He was a seminar speaker for Foot Levelers, Inc., for more than 15 years. He brought not only knowledge and experience to these seminars but also his warmth, humor and compassion. He conveyed more than words on a PowerPoint slide to his students; he taught them by his actions how to find the good in every situation, in every person, every day. His optimism and gratitude cannot be forgotten. He always found a way to make someone laugh or charm them with his sense of style or brighten their day with a kind word. He knew that being a chiropractor was more than being a healer and used his profession to help others not only with his hands but also with his words and actions.
 
He did not do just what was expected of him; instead, he exceeded expectations by always doing more than required. He served on multiple boards, clubs and chiropractic associations, usually in a leadership role. As a graduate of Palmer College of Chiropractic, Dr. Lee was a member of the post-graduate faculty at both Palmer and Parker and was the former president of the Michigan Chiropractic Society (a precursory organization of the Michigan Association of Chiropractors (MAC)). He received numerous awards for his dedication and diligence to chiropractic, including “Chiropractor of the Year” in 1998 and the MAC “Pioneer Award” in 2010 for continued service to the chiropractic profession on the state and national levels. 
 
Dr. Lee is survived by his wife, Terri Jo; his two daughters, Elexis and Elyse; one grandson, Dylan; and one grandchild on the way. 
 
We felt the best way to remember Dr. Lee is to hear how he affected those who had the pleasure of working with him and calling him friend:
 
“The supportive members, dedicated leadership, and loyal staff of the Michigan Association of Chiropractors are deeply saddened by the loss of our dear friend and colleague, Dr. Kirk A. Lee. Although our grief is all encompassing, we are comforted by our fond memories of Kirk and our sincere appreciation for all he contributed to chiropractic. 
 
“First and foremost, he lived for his family. He was a wonderful, involved father and husband who put his wife and girls above all else. His love for his profession, his friends, and his colleagues was clearly evident to all who knew him. His volunteerism with his state associations and national speaking engagements is unmatched, and his accomplishments too numerous to list. He is remembered as one of the most important architects of our merger, and one of the most effective association leaders ever to serve in our state.
 
“We are blessed with memories of his kindness, honesty, unbelievable work ethic and love for his profession. Always positive and ready to share a laugh, Kirk was a true friend to all who were lucky enough to know him. We will always remember his cheerful ‘Hi, Honey’ when he called the MAC office and his ability to warm our hearts. Many will also remember his stylish flair, including his fancy suits, bow ties and suspenders.
 
“Although he is no longer in our vision, he will always remain in our hearts and minds. We love you Doc. May you rest in peace.”
 
-- The Michigan Association of Chiropractors

Reflections from Foot Levelers Staff Members

“Dr. Lee was a very humble and generous person. I never heard him utter a bad word about anyone or anything. He really did care about people and put others’ needs ahead of his. He would gladly stay after a seminar to talk to the doctors attending. We were honored to have him as a featured speaker in our speakers’ bureau for more than 15 years. He was an expert in sports injury, but he taught doctors so much more. He was a true gentleman and will be missed.”
 
-- Dwayne Bennett, 
Foot Levelers President
 

Treat people as if they were what they ought to be, and you help them become who they are capable of becoming. - Goethe

“I  had the pleasure of working with Dr. Lee for about 15 years. He was probably the kindest man I’ve ever met, so considerate and caring. We had a bond over the color purple—mutually our favorite color. He frequently wore purple ties, shirts and Palmer logo clothing (their school color is purple). We also got into a conversation once about collectibles. He was a huge Mickey Mouse fan, and I mentioned that I collected Cows on Parade figurines. At least a year later, I was with him at a seminar, and he had a gift for me. He and his wife had been in San Antonio, and he brought me a cow from there. Just for him to remember that I collected them was totally impressive, and how sweet for him to buy one for me.
 
“At a seminar, you might expect prominent speakers to walk into a room and immediately start giving the seminar representative from Foot Levelers instructions on how they want things set up. Dr. Lee was exactly the opposite! He always asked the rep what he could do to help them set up their exhibit table and the same when it came to packing up. We always treat our speakers as though we are their assistant, but it was difficult with Dr. Lee because he was always there trying to help us! It’s for that reason that I would always send my new seminar travelers on their first seminar alone with Dr. Lee. I  knew they might be nervous and that he would not only help them, but make them feel so comfortable. I  guess that’s why I heard the same thing from so many of my reps when they found out about Dr. Lee’s passing: ‘I  remember that my first seminar was with Dr. Lee.’
 
“The world lost a true gentleman. He will be missed by so many.” 
 
 --Yolanda Davis, 
Foot Levelers Seminar Manager
 
“As a writer at Foot Levelers, I  had the pleasure of working with Dr. Lee for more than six years. He stands out as a positive person who always had something nice to say to me and frequently asked about my day and how I was doing. He was an absolute joy to work with, and I honestly looked forward to every time we spoke because he made my day better. He didn’t just meet the deadlines we set for him; he would do what I asked and then some. His impact on the chiropractic world is big, but the positive impact on each life of those who knew him is even larger.”
 
--Jeanette O’Neill,
 Foot Levelers Senior Communications Specialist
 
“I  remember Dr. Lee always being so kind, caring and professional. When he spoke, you could feel his energy and passion for what he did and for helping others. He also had a unique style that involved wearing his Michigan colors (blue and gold) on a bow tie or his purple Palmer clothing and suspenders. He and his wife loved going to Disney World because he loved Mickey Mouse and all the magic around there.
 
“I  will never forget that my first seminar at Foot Levelers was with Dr. Lee. I  remember I got in late from a delayed flight and ended up driving to Kentucky. He waited up and met me in the bar. He bought me a drink, and we just talked and got to know each other and strategized our game plan for the morning. He told me how he loves Christmas and that they had a tree in every room. I  have never forgotten this detail and even had him send me pictures. I  just thought it was the coolest thing. I  can’t remember how many, but I  know it was 10+ trees and each had its own theme. He was truly a wonderful father, grandfather, husband, doctor, friend and person in general. He was full of magic himself and will be missed by so many.
 
“As I reminisced about Dr. Lee, I  had to look at some previous emails and noticed his signature and the following quote on all his emails. This is truly what he lived by: ‘Treat people as if  they were what they ought to be, and you help them become who they are capable of becoming.’ – Goethe”
 
--Heather Warfe,
 Foot Levelers Seminar Coordinator
 

Memorial Contributions for Dr. Kirk A. Lee may be made to:
Michigan Chiropractic Foundation
c/o Dr. Kirk A. Lee Student Scholarship Program
416 W. Ionia St
Lansing, Michigan 48933
(517) 367-2225
www.michirofoundation.com


 
How to Document the Effectiveness of Medicare DME-Approved Lumbar Braces
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Written by James C. Antos, D.C., DABCO   
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.
 
lumbarbraceIn 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:
  1. The patient is sitting.
  2. The doctor/attendant instructs the patient in how to perform the “get up and go” task.
  3. 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:
  1. 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.
  2. 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. 
  3. 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
 
What if Insurance Reimbursement Went Away Tomorrow?
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Written by Paul S. Inselman, DC   
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.
 
moneyspigotThis 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
  • Advertise more 
  • 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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it
 
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