A friend of mine, a chiropractor, was listening to the tail end of a talk I was giving in Florida, and after the talk, asked me to explain this cheeseburger thing to him.  I told Mike, (that’s his name) that the cheeseburger phenomenon is something we coined to explain the product problems that we encounter which causes us to redesign our existing product line.  “Explain,” he said. 

Well it’s like this:  You have fifteen chiropractors on the same block and all of them do basically the same thing.  How most of them try to differentiate themselves is by word speak, technique, marketing, hurt and rescue, and other various strategies.  It’s like when you go in the bathroom and see the poster, “As the twig is bent so grows the tree.”  We call that a symptom of product problems. 

“Product problems?” Mike replied. 

“Yep, product problems,” I said.  “Take that cheeseburger analogy thing, replace the fifteen chiropractic offices with cheeseburger stands.  The owners of the cheeseburger stands try to differentiate themselves by rearranging the items between the buns.  The first guy sticks the meat on the bun first, then the cheese, then the tomato, lettuce, onion and ketchup.  The second guy has a better idea.  He puts the cheese on the bun first, then the meat, next the lettuce, ketchup then onion.  Of course, the third fourth and fifth guys do their own arrangement and all feel like they are unique compared to the other fourteen cheeseburger stands. 

“You know, just rearranging the items on a display doesn’t make a new product.  If it was a new product, the cheeseburger stands would be able to charge much different prices and, like the chiropractic office, it seems to me the prices all are about equal.  Equal price, equal value.  Imagine that.  No real way of differentiation.  In our business, we call this a product problem, and, when it emulates the cheeseburger example, it’s time to look at our product and figure out how to really differentiate from the competition and re-engineer what we offer the customer.

“You call them  patients; we call them customers,” I said to Mike. 

Here’s another analogy.  The patient or customer who walks down the street has a wallet with two twenty-dollar bills in his or her pocket.  The money doesn’t care where it gets spent, but the owner of the money evaluates all their spending options.  Pizza Hut, the department store, overdue bills, a gift for someone special, or the chiropractor, and so on—all are options available to spend the money on.  How all of those products stack up is what we call purchase hierarchy.  Which one of those items or combination of them wins out is based on the value the customer places on them.  This is where the tricky part comes in.  How much value the customer places on it is based on their satisfaction index.  We gauge the satisfaction index by the response the customer has to our product without a “sales pitch”.  The duct tape test.

“The duct tape test?” Mike asked.

“Look at it like we do, Mike,” I said.  “If you place a piece of duct tape across the salesperson’s mouth, (this can be a doctor, CA, etc.) and if the product is not accepted by the customer without the pitch, or the customer cannot be convinced to come back and purchase more product without a pitch, you have to start looking at your product and asking why the customer doesn’t perceive value.”

Now I had Mike right where I wanted him.  “Do you have one of those As-the-Twig-Is-Bent-So-Grows-the-Tree posters?” I asked. 

“Yeah,” he said. 
(Don’t tell me, it’s in the bathroom!)

Dr. Mike was pretty quiet by this time, but I asked if he did things like nutrition, electrotherapy, ultrasound, traction and other treatments in addition to his adjustments. 

He said, “Yes.”

Now for the real tough questions.  I asked, “How many minutes do you apply electrotherapy on the patient during a session. 

He replied, “About 12 minutes.” 

I replied, “Oh the electric aspirin.”  I explained to him that there are dozens of treatment options other than the “electric aspirin” that will really send the customer—I mean, patient—home really feeling great.  How about traction? 

Do you do real traction or just rollers. 
“Just rollers” he replied. 

“Just  babysitting the patient,” said I.

“When you do ultrasound, do you treat only three times the ERA of the crystal or do you paint the wall?” I asked.
This is when Dr. Mike stopped answering my questions. 

“Well, Mike,” I said,  “the good news is you’re a perfect candidate for product repair.  Just imagine, if we fix your product offering in all aspects, the patient satisfaction index will go up and your practice will truly be different than the others in the neighborhood.  In fact, the better your product gets, the more of those tacky posters you’ll be able to remove.” 

“Great,” he said.   “They really make the place look pretty unprofessional.”

My advice to Dr. Mike was the same advice I give to all of the chiropractors I meet in my travels worldwide through my work.  It hasn’t changed for twenty years.  When you fix the product, the sales come.  When you do the same thing over and over and expect different results, you have a problem. 

Think about this example.  If we sent twelve employees from the local McDonald’s to an Anthony Robbins seminar for a weekend, do the cheeseburgers taste different on Monday morning?  Are the Happy Meals any better than they were on Friday?  The fact is enthusiasm is a wonderful catalyst, but you need a new product together with the catalyst to really get all the benefits.  Imagine, if we took those same twelve employees and, in addition to the “head repair” they get with Tony Robbins, we gave them an entirely new improved product.  Instead of just “supersizing” every order, they were turning on all the customers to the “new product line”.

So here was my prescription to Dr. Mike:
When you offer adjunctive therapies in your office, they are only as good as the research behind them.  After that, you need to purchase all of your “non chiropractic” additions from reputable companies and knowledgeable distributors.  The lack of training you get from the salesperson hurts your practice and product more than you will ever know.  Only buy from a company that supports the product with in-office training for you and your staff, and backs it up with clinical data from accepted publications, not anecdotal information.  Remember, the only one that loses is you, because the product you offer the public is not as great as it could be.  Demanding excellence from the people you buy your therapies from will help improve the product you deliver to the patient.  Most importantly, if the claims sound too good to be true, they are.

Second was the most important advice to Dr. Mike.  It was the advice about the risk to his license.  I explained to Dr. Mike that taking the information the salesperson gives them on billing codes was like lending his license out for someone else to use.  It is crazy to take the billing advice the salesperson or manufacturer gives you at face value. 
Improper billing of CPT codes is insurance fraud.  Billing codes for therapies that do not have the effect the codes imply is also fraud.  When a salesperson gives you billing advice, remember to always call your billing consultant to make certain you aren’t creating a situation in which, under an audit, you will have to pay back thousands of dollars you probably spent a long time ago.  Let’s face it, “Whose license is it anyway?”  Do you think that salesperson has as much at risk as you do?

Well, Dr. Mike was mumbling something about, “I don’t even eat cheeseburgers, I’m a vegetarian,” while he walked away. 

But I think he learned a valuable lesson about product and the value the customer places on it. 
As he walked further down the hall, I said, “You know, Doc, your patients will appreciate all the changes you make because, when you fix the cause, the symptoms go away.”

Chris Peetros has spent the past 20 years developing products for the chiropractic profession. Currently, he is the National Sales Manager/Specialty Products Division and Chiropractic Products Division Manager for the Chattanooga Group in Hixson, Tennessee. Chris has spent the past 10 years developing the Ergostyle Adjusting Table product line and his most recent project, the Triton DTS Spinal Decompression System. Chris can be contacted through the Chattanooga Group, Inc. He can be reached at 800-592-7329.

As a consultant, I find more and more doctors turning to Personal Injury.  Why?  The great bank robber Willie Smiths was once asked, “Why do you rob banks?” 
His response was, “That’s where the money is.” 
As regular insurance is becoming more difficult to collect, more and more DC’s are turning to PI.  Why?  Again, that is where the money is.  This is a bad place to put your practice solely in.  The key is to diversify.  PI should be part of your practice, but not 100%.  Otherwise, you will be put into a position of failure, if regulators make changes.  New York already has PI limits; more and more states are looking into changing the current model.  It should be your job to work with national and sate representatives to bring back equality in our profession.  However, many of you will continue to do PI.  If you do, know the rules and do it right.
First and foremost, don’t just beg attorneys for patients.  Attorneys refer to doctors that are thorough and whom, they believe, will add value to their case.  Remember, their income comes from the settlement.  The larger the settlement you can help the attorney procure, the more valuable you are to his team.  He/she is out to make a living.  Provide him/her with great reports, know how to do impairment ratings, know how to document your file.  Be professional.
If you’re going to travel the auto insurance route, you had better know how to navigate around potholes. Follow these tips for circumventing billing roadblocks when filing auto insurance claims for motor vehicle accidents (MVA’s):

Your Manual for Billing Auto Insurance

• Keep good records.  Save all relevant information from patients, insurers and other professionals involved in MVA’s.  Get pictures from the accident, and do a thorough consultation.  Get copies of and other doctor or hospital records.  Save your e-mails especially, because you can make copies of conversations and keep them in the patient’s chart.  Keep track of key phone numbers, contact names, and dates of conversations, and mark your information in the computer with special codes so you can run reports on them.
• Establish a hospital contact.  Many patients go to the hospital first.  When working with my MD/DC clinics, we know who is on staff at the hospitals.  We let them know we specialize in SOFT TISSUE INJURIES.  We provide these emergency room doctors with information that is viable to them.  The key is establishing yourself as the expert.  In addition to establishing good communication with agents, attorneys, the insurer’s claims department and the patient, you should look for a hospital contact to find out useful information regarding auto or health insurance, especially from inpatients whom the contact can visit.  Remember these contacts take time; be patient.
• Fill out your insurance claims completely and send them immediately.  Send a copy of your initial exam to the attorney as well as the insurance company.  I NEVER CHARGE FOR THIS INITIAL REPORT.  Get the insurance form filled out as completely as possible.  Contact auto insurance as quickly as possible, since there’s usually a medical maximum on the policy.  The first claim in gets the money, so out-kick competitive submissions with speedy filing.  Know if there are limitations and know your state laws in regard to billing.
• If health insurance is involved, prepare for denials.  Don’t be surprised if you have trouble billing health insurance after the patient’s auto insurance tops out.  If you’re lucky enough, health insurance will pay the claims.   When you bill health insurance for the remaining amount, you need to obtain a letter from the auto insurance stating that auto insurance has maxed out, and be prepared for health insurance denials.  One medical office reports that it can rarely get an HMO or PPO to extend the filing deadline when a patient’s auto insurance is exhausted.  So, the office bills the health insurance from the start, using the ICD-9 code for MVA’s.
  One way around this problem is to notify the HMO or PPO before you do any billing,  When you encounter an MVA that involves an HMO or PPO, make sure you get the referral from the HMO or PPO, because the MVA will most likely top out quickly.

Buckle Up for Patients
Involved in Auto Insurance Lawsuits

Strap in tight.  Your automobile accident patient’s legal proceedings can mean a long, bumpy ride for your office, even if you’re not directly involved.  Avoid financial dents by practicing these safety tips:

• Immediately talk to the lawyer or paralegal on the case.  They will be very honest with you about whether they think there is a good lawsuit.  This information will give you a good idea about your patient’s future financial situation.  Often it is the paralegal that runs the case.  It is the paralegal that often refers the case.  The paralegal is a good person to educate.  Are you able to educate the paralegal on the value of the case?  If you answer NO to this, you need to attend more seminars.  Kaplan (no relation) and Croft are two excellent ones in regard to PI.
• Provide medical records when requested in a timely fashion in order to protect yourself.  In many states, like Florida, if your claim is not filed in a timely manner, the insurance company does not have to pay you.  Reporting is part of health care today.  Keep good notes and records; this is the key to referrals. 
• Obtain a lien against the settlement by contacting the patient’s attorney.  The lien basically states that the attorney and patient must pay your bills out of the settlement before the patient receives his/her portion.
  Beware of two dangers with liens.  First, a hospital lien takes precedence over a physician lien, so you may not get paid.  Also, an “unscrupulous” attorney may not honor your lien.  If that happens, you should contact the BAR.  You have worked hard for your money.  Everyone must play by the rules.
  Some attorneys will not sign a lien.  Be careful of these attorneys.  Have the patient sign a lien.  If no one will sign a lien, consider not taking on this case.  You are setting yourself up for more problems.
• Follow up on the settlement’s progression.  Write a reminder to check up on the account, and keep in touch with the lawyer’s office and the patient.  Set up a meeting with the attorney.  DO NOT CHARGE FOR THIS MEETING.  Be a doctor, not a salesman.  Talk about the case only.  Review your notes; help him or her establish value to the case.  Do not ask for referrals at this meeting.
• If all else fails, turn to outside collection agencies.  If your patient loses the court case but doesn’t end up paying you, what do you do?  Do not forget about the money.  YOU EARNED IT.  Consider sending the claims to an outside collection agency, which has “better sources” for collecting.  Your patient may receive a settlement large enough to cover the medical expenses, but may try to skip out on paying.  This is why a lien is so important.  Try to have the attorney pay your bill upon receiving the settlement money.  A good relationship with the attorney can help you here.  Put in the time that is necessary.
• Integrate your practice.  Many of my clinics add an MD, this way they improve their chance for a greater settlement.  By providing both medical and chiropractic records, you build up twice the case.  Often this results in a larger settlement.  Remember, this is what attorneys want.  This is what they do for a living.  The PI market is also getting competitive on their end.  They want to make more with fewer cases.  An MD/DC clinic offers a “one stop shop” for PI, by providing chiropractic care and medical care.  It almost removes the paper IME component.  This also helps our profession, as now MD’s validate chiropractic care.  For the purist at heart, remember B. J. Palmer had MD’s working in his rehabilitation clinic and documenting the validity of chiropractic.
• Be Professional.  The key to a PI practice is being professional.  Prepare your file with care.  Put the time into your records and reporting.  If you are good, attorneys will find and court you.  The PI world is a competitive world.  Scout the competition and develop a better game plan.  A more complete and professional plan.  Also, be proud of what you do and do it with excellence.  If you do that, you will do well.

Dr. Eric Kaplan is the CEO of MBA, Inc., one of the nation's largest multi-specialty consulting companies.  Dr. Kaplan ran and operated five  of his own clinics, seeing over 1000 patient visits per week.  He is the best-selling author of Dr. Kaplan’s Lifestyles of the Fit and Famous, endorsed by Donald Trump, Norman Vincent Peale and Mark Victor Hansen.  He was a recent commencement speaker at New York Chiropractic College and regularly speaks throughout the country.  For more information about Dr. Kaplan or MBA, call 561-626-3004.