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Behind the News
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Written by Deborah A. Green, Esq   
Tuesday, 14 September 2004 22:03

OHIO:  A recent series of cases, all based on the same set of facts, got a pair of Ohio chiropractors as well as other health care providers in deep trouble. The facts were the same in all situations. In exchange for referring patients to a diagnostic company, the providers received “lease” payments for office space. The amount of payment under these sham leases was directly related to the number of referrals made, and had no relation to the actual fair market value for rental of the leased space. The tests were found to be medically unnecessary.

The chiropractors pleaded guilty. One DC was required to pay $50,000 to defrauded insurers, and she was lucky; the other DC had to pay in excess of $67,000, spent four months in prison and another four months in home detention.

The government is not happy with doctors who receive money for the referral of patients. If you do enter into a business arrangement with a referral source or with someone, to whom you refer patients, make certain that your business arrangement fits into a bona fide safe harbor.

Keep in mind that the federal anti-kickback statute prohibits knowingly and willfully soliciting, receiving, offering, or paying anything of value to induce referrals of items or services payable by a federal health care program. The government considers kickbacks to be harmful because they distort decision-making; cause over utilization; increase costs to the federal health care programs; and result in unfair competition by freezing out competitors unwilling to pay kickbacks.

Both parties to an impermissible kickback transaction may be liable. Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment for up to 5 years, or both. The government may also initiate administrative proceedings to exclude persons from the federal health care programs or to impose civil money penalties for kickback violations.  Many states have similar laws in effect so, even if you do not treat Medicare/Medicaid patients, you may still be liable under your state’s laws.

What Does This Mean to You?  In order to avoid problems, consider the following issues when analyzing a proposed transaction—they signify potential problems.

1. Will the new source of income generated be provided by your existing patients?

2. Will the company that you’re working with pre-dominantly, or exclusively, service your existing patient base (or patients under your control or influence)?

3. Is your primary contribution to the venture referrals?

4. Are you required to make little or no financial or other investment in the business, delegating almost the entire operation to the other party, while retaining profits generated from your captive referral base?

5. Is the practical effect of the arrangement, viewed in its entirety, to provide you with the opportunity to bill insurers and patients for business otherwise provided by an outside party?

6. Does the remuneration from the venture to you (i.e., the profits of the venture) take into account the value and volume of business that you generate?

7. Is someone making you promises that sound to good to be true?

8. Is the other party telling you that you can rely on his lawyer and that you do not need to go to the expense of hiring your own?

If your answer is, “Yes,” to any of the foregoing questions, make sure that your health care lawyer carefully reviews this “terrific deal” before you, too, are discussing a “deal” of a different nature with your local district attorney.


If you have any questions with regard to the above or with respect to any other legal health care issues, FAX your questions to Deborah A. Green, Esq., at 954-971-3787 or call 954-971-7778 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it . In future columns, she will be answering those questions which are of interest to the broadest audience.

Ms. Green has been a practicing attorney since 1977. She is admitted to the practice of law in the State of New York and Florida and is a member of the American Health Lawyers Association, the New York State Bar Association Health Care System Design Committee, the New York State Bar Association Health Care Providers Committee, the American Bar Association Health Law Section and the Florida Bar Health Law Section. She has formed numerous multi-discipline practices throughout the country.


Because this column is being presented to you by an attorney, it would not be complete without a disclaimer. This column is provided subject to and governed expressly by the terms of this disclaimer. This column is provided for educational purposes only. The accuracy or timeliness of the information presented herein is not warranted. The information presented herein is not intended to be advice as to a specific fact pattern with which you may be presented.  Accordingly, please note that the information contained herein is not being presented as legal advice with respect to any matter and that no attorney-client relationship is hereby established.

It's a Good Time to Take Inventory
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Written by Suzi Plank   
Tuesday, 14 September 2004 21:59

The children have gone back to school and summer is over—the season, if not the heat.   Many offices see an ebb and flow to their practice volume during certain times of the year and summer can be one of the more relaxed times.  The pace of activity usually accelerates going into fall.  Along with your regular schedule, there is an abundance of conventions, seminars and trade shows you can attend.  You have your choice of courses for continuing education or additional training and certifications.

Many people are accustomed to making resolutions as they celebrate the New Year.  Where business is concerned, the end of summer almost seems a more appropriate time for this process.  Evaluating the different facets of your practice at this time of year can provide the time and resources to adequately research and plan any changes or additions you might wish to implement in your practice.

Several basic questions should be considered when assessing diagnostics in your practice. Honesty is the best policy when answering.  There is no pass or fail, just the opportunity to gain insight to improve your practice and the health of your patients.  It may be helpful for your associates and staff to also provide responses.

1. What diagnostic equipment do you have in your office?

2. What diagnostic procedures and tests do you regularly use?

3. Are you taking the full and best advantage of your current diagnostics?

4. For each of the tests or procedures, can you answer the following:

 a. What information will be gained?
 b. How will that knowledge help the patient?
 c. Do you know how to document the necessity for the procedure?
 d. Do you document and use the results from the test or procedure?

5.  Are you being reimbursed appropriately for the diagnostic procedures you bill?

6.  Are there “new or improved” procedures or equipment available?

Compare your answers to the first two questions—do you have diagnostic equipment in your office that you do not use regularly?  If you have equipment not being utilized, consider why you no longer use it.  Was the equipment difficult to use? Did it take too much time, or not provide useful information? Were there problems when billing for the test?  Was the equipment ever used on a regular basis?  Are there diagnostics you previously used regularly but, now, do not?  Why not?  If you were able to resolve or correct the problems that led to your rejection of the test or procedure, would you reconsider its use?  Is there a habit in your practice of acquisition and abandonment?  (Shiny toy syndrome!)

Questions three, four and five should be correlated to each other as well.  If you and your associates are not able to provide appropriate answers to all aspects of question four, it is doubtful you are realizing the full potential of diagnostics.  Lacking sufficient necessity and documentation, it is also likely reimbursement is being denied or requires additional time and effort to collect.  Billing and collections staff should have the same information about diagnostics readily available to them, especially for tests or procedures you bill.  There is a general consensus in diagnostic collections; more expensive procedures require submission of more documentation of necessity and efficacy in order to obtain payment.

You now have an idea of the equipment, tests and procedures that have proven most beneficial to you and your patients.  In your evaluation, did any patterns develop?  The results allow you to recognize strengths as well as weaknesses in your diagnostic protocols.  What resources are available to correct or improve the deficiencies in your existing systems?  Would training or certifications help?  Many seminars and courses are available for fall and winter.  Do any of your vendors make in-service presentations available to you and your staff that could provide additional training or documentation?  These are just a few suggestions.

And lastly, of course, new and improved equipment is available.  Your review may show the benefits of new or upgraded equipment or implementation of advanced diagnostic procedures in your practice.  Your analysis can help prevent repeating the same types of mistakes and will enable you to take the full and best advantage of diagnostics for your practice and the health of your patients.

Ms. Plank has an extensive background in medical and facilities management.  During the past 15 years, Ms. Plank has provided technical and management services to healthcare providers, specializing in radiology and neurology.  She is currently the Vice President of Corporate Services for Practice Perfect.  Contact her at This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or visit www.dahan.com.

The Business of Diagnostics
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Written by Suzi Plank   
Thursday, 08 July 2004 21:38

Diagnostic procedures used by many chiropractors fall into two basic business classifications:  those that represent billable services for the doctor or clinic and those that are referred to another practitioner or facility with no financial component to the referring chiropractor.
Do It Yourself

In many cases of the tests or proceures that can generate billing, the chiropractor has a choice of “doing it yourself” (DIY) and providing the service in-house.  This usually represents full ownership/long-term equipment lease of equipment and the doctor or staff trained and qualified to perform the procedure.  Interpretation of the testing may also be required.  X-ray exams are a billable diagnostic procedure commonly offered in-house by chiropractors.     


The diagnostic procedures you refer out should be reviewed on a regular basis from a business management perspective.  What is your average monthly referral volume for each specific procedure?  What would your costs be in the delivery of the service?  Is the referral number high enough for you to consider providing and billing the service?  Is the procedure in the scope of practice for your licensed professionals?  Does it represent additional liability to your practice?  Is the procedure reimbursable to your practice structure by insurance plans? Would it make sense… professionally and financially?

The answers to these questions may identify revenue potential for your clinic.  Although your monthly referral average for procedures such as MRI tests may not justify the expense of operating an imaging center, the number might be sufficient to justify purchasing or leasing time at a local facility, particularly if your referral average has a steady and sufficient base.

There are usually costs involved if you plan to bill for something.  Insurance companies wonder where the value is if the test or service did not represent costs to you, in the form of time, the training and expertise necessary to provide the service or the hard costs of overhead and equipment.  The logic is, if you did not have to do anything and it did not cost you anything, then it probably isn’t worth anything in reimbursable terms to you.


Outsourcing, the term and practice, has been in use by hospitals and large health care providers for years.  Outsourcing is really just hiring someone, a company, a physician, group or other entity, to provide specific services for or within your facility.  The outsource provider is hired to supply services, sometimes which may be billable by the hospital/clinic or it may represent a separate entity within the medical complex which charges for its own services, just like another store in the mall.  Radiology and laboratory services are departments that are often outsourced.   

Neurodiagnostic procedures, musculo-skeletal ultrasound, functional capacity evaluations, videofluoroscopy and nutritional testing are just a few diagnostic services many chiropractors regularly employ in their analysis and diagnosis of their patients.  These services are available as referrals, DIY and outsource.  Many of these diagnostic tests are reimbursable when billed by chiropractors.

It may be within your financial capability to purchase or lease equipment to offer these services, but who is going to operate it?  Interpretation of the data, training, certification and regular and consistent use of the equipment are significant factors that should be contemplated.

Outsourcing can be a cost effective method enabling doctors to provide more advanced diagnostic procedures without requiring large capital expenditures for equipment, staffing or training.  Contracting with an outsource provider can minimize or fix your delivery costs for these services.  There are various contract and agreement structures when using outsourced services.  However, if the service does not cost you anything in money or time, it may not represent a service that is reimbursable to you.  Additionally, an outsource provider can bring experience and knowledge to you and your staff in the necessity, application and use of the diagnostics as well as billing and collections assistance.  This support aspect supplies you a resource that can jumpstart your ability to successfully implement a revenue producing diagnostic service in your clinic.

Diagnostics are an important resource in your care of patients.  Consider the appropriate diagnostic options available, whether referral, outsource or DIY and diagnostics may represent an untapped resource for you as well. TAC

Ms. Plank has an extensive background in medical and facilities management.  During the past 15 years, Ms. Plank has provided technical and management services to healthcare providers, specializing in radiology and neurology.  She is currently the Vice President of Corporate Services for Practice Perfect.  Contact her at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

A Primer on "Decompression"
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Written by Jay Kennedy, D.C.   
Thursday, 08 July 2004 21:36

There are many treatment options available to chiropractors today.  Regrettably, many of them carry more hyperbole than technology.  Wildly expensive “cutting edge” technology can have its advantages, but can also really hurt your practice (and your credit scores!).  However, there are treatments which have proven their value and relevance over the last few years of successful clinical use.  If a treatment method is put to the test in hundreds of clinics and earns unreserved praise, with over 40% buying a second unit within the first year, it is probably not only an excellent investment but perhaps a necessary one as well. Such is the case with axial decompression/decompressive traction therapy.  My clinical experience with decompression has been a ten year clinical “grand slam”; a journey with few regrets—even in the face of having spent over $100,000 each on our first units.  Both clinically and as a practice builder, I have yet to see any other treatment as impressive.

In a very rudimentary sense, there are really only 2 passive mechanical treatments you can administer to the spine:  Thrust and stretch.  To limit your patients to just one option because of your own limited paradigm may be bad for them and bad for business.  Think about it.  Compressed discs are in need of “decompression” and avascular tissues are in need of renewed blood contact.  These effects are logically much more likely via stretch than thrust. (By stretch, I mean a prone or supine, restrained, +10 minute cyclical protocol).

Additionally, of course, mechanoreceptor types I, II & III are activated during “traction”.  Decompression is very likely to foster both pre-synaptic inhibition as well as phasic healing through enhanced blood and fluid exchange, a double shot, so to speak.  This basic fact seems somehow lost on many chiropractors, but it is incredibly well accepted and intuitive to the general public.  Of course, science is one thing; business is another.  We are in the unique position of being able to introduce our patients (and community) to scientific advancements and treatment methods and, in the process, get more business for ourselves.  This win-win situation is the essence of success.

The success of “Activator” practices and various pulsed adjustment devices is not hard to understand, if you place your “ear close to the rails”, i.e., listen to the general public.  Many people are afraid of or apprehensive about manipulation.  Many practices have found adding gentler adjusting methods and decompression therapy garners far and away more new patients than it ever discourages.  Adding additional methodologies deflects much of the criticism related to being limited and “dangerous”.  We have had hundreds of patients say, “My doctor said it was OK.  I come here because you’re gentle and use that ‘stretch treatment’.”  Additionally, proven and cost effective methods simply give a greater opportunity to appeal to a wider range of patients.  It establishes your practice as more eclectic and, as a result, fewer patients will “jump ship” looking for a different or more “thorough” approach (because that’s what you offer!).

I believe I have created that eclectic practice with the addition of decompression, stabilization exercises and various gentler adjustment methods.  This combination is so powerful as to virtually eliminate patient attrition due to treatment “failure”, per se.  That’s not to imply some patients do fail to respond, but we are able to be much better at prognostication and when to refer to other specialists.  An eclectic treatment practice allows a much easier determination of when “done is done”, something some practices may find difficult to identify.  If the patient didn’t improve, was it because they needed “supine decompression” and not flexion/distraction (they couldn’t lie prone) vs. rotary manipulation?  Though it is based on my own empiricism, I have seen very few patients with referral pain gain dramatic relief with adjustments if they had first “failed” decompression therapy.

Separating yourself and your practice from “the other guy” is no easy task.  However, offering a variety of reasonable, effective and safe treatment options makes it much more likely.  Most practices now offer manipulation (89%), flexion/distraction (65%) and modalities (75%).  As Napolean Hill said, “Being a little better that mediocre can get you great things in life.”  My initial $200,000 investment 10 years ago has paid off nicely, but not without some financial stress over those years!  At that time, more cost effective units were unavailable.  Now that decompression therapy is available for about the price of a quality adjusting table, there’s simply no good reason to miss out on it’s numerous clinical and business advantages.  My grandfather used to say, “A man who sees his life as small and limited makes his life small and limited.” I don’t want that as my legacy.  Stretching the limits of my practice has helped me build a reputation and practice I’m proud of. TAC

Dr. Jay Kennedy has been practicing Chiropractic Biophysics (CBP) in Western Pennsylvania since graduating Palmer College in 1987.  In the last nine years, he has owned and operated several decompression systems, treating over 2000 patients on them in his multidisciplinary clinics.  He lectures extensively and has authored various articles on axial decompression.

New York Guard Chiropractors Attend Seminar
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Written by TAC Staff   
Tuesday, 08 June 2004 20:18

Florida Chiropractor, Dr. Alan M. Creed, one of the leading authorities on instrument adjusting in the chiropractic profession, gave a seminar, in March 2004, to the chiropractors of the Chiropractic Services Unit (CSU) of the 244th Medical Clinic of the New York Guard (NYG).  Dr. Creed, himself a US Army veteran and a Past-Commander of a veterans post, donated his lecture to the NYG as an act of appreciation for the service the Guard rendered to the participants of the post-9-11 operations.  Having read that the CSU had rendered over 200 chiropractic treatments each day during the crisis, he felt compelled to contribute his share to the overall effort.

From Left: Capt. Richard Zipperman, DC; Major Floyd Miller, DC; Capt.  David Hecht, DC; Alan Creed, DC (front center); Capt. Richard Romeo,DC; Capt. Charles Marino, DC

Dr. Creed was welcomed to Camp Smith by LTC Patrick Delamere, DC, the NYG Chief of Chiropractic Services and MAJ Floyd Miller, DC, the Deputy Chief.  In their welcoming remarks, LTC Delamere and MAJ Miller told Dr. Creed, “It is a proud day in the history of the CSU to host his seminar.  The chiropractors of the NYG were the first fully-commissioned chiropractors in any military organization, and the fact that we could host such a prestigious seminar is a further sign that chiropractic and the military are to be partners in the 21st Century.”

Dr. Creed’s seminar stressed the various techniques of specific spinal correction with emphasis on the established protocols for evaluation, treatment, and assessment of the soldiers’ health issues. 

The seminar was sponsored free of charge by Foot Levelers, Inc., of Roanoke, VA, and Impac Instruments of Salem, OR.  Foot Levelers and Impac provided Dr. Creed’s transportation and lodging and further provided the instruments and visual aids that made the seminar possible. Continuing Education Credits, as mandated by New York State law, were provided by Texas Chiropractic College.

Dr. Alan Creed presents a nation-wide seminar series, Boost Your Practice: Bridging Techniques, Styles & Technology, which is approved for Continuing Education Credits by the Texas Chiropractic College.  He has a chiropractic practice on Key Biscayne, FL, and can be contacted at 305-365-7988 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .  You may also visit his website: www.dralancreed.com. TAC


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