Practice Operations

Seven Deadly Business Traps
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Practice Operations
Written by Richard Busch III, D.C.   
Monday, 21 February 2011 17:13


he following are traps that many doctors, as business owners, fall into and, if you can avoid them, you could make a lasting change in your business.

Most doctors are very proud of being true to their philosophy of healthcare and being a chiropractor, but doctors aren’t trained or naturally talented in all aspects of business, although, the amount of money many owe in student loans could fund a startup business.  However, a very good doctor may not invest in the time, funding and implementation of important aspects of his or her business. As doctors, we have to be business people, out of necessity. Just take a quick assessment of your own office and see if you can give yourself a good grade for avoiding the following business traps:

1. Slipshod Accounting:  Correct accounting can diagnose what is right and wrong with your business.  You can produce an income statement in a matter of minutes from any accounting software. That is, if you have input the data.  This shows if your formula for making money is working.  Do you understand your ratios of expenses to sales?  Yes, as doctor, you have sales.  This is what makes you profitable.  You must have an understanding that you must gross X$ amount to see X$ amount of net profit.  It is not going to work to say, I hope I can make $300,000 this year.  Slipshod accounting will get you into trouble and worse is having no accounting at all.  You must have a grasp on all your costs, including components such as computer upgrades and other orphan costs.  Then you can fine tune profits.  Accurate accounting can correct aimless direction.  A doctor doesn’t have to know all the answers to all the questions, but he or she does need to know all the questions and employ someone who can help achieve the answers, i.e., a good accountant and bookkeeper.

2. Fear of Fees:  Discounts on fees really increases your “Cost of Sales”, and you must keep that in mind.  Free offers for examinations, X-rays and first adjustments have costs associated with them.  There are the costs of the doctor’s time, patient confidence and income lost from “free offers.”  And you are acquiring additional liability for which you have not been compensated. You need to truly understand your costs, and pricing your fees too low is a significant sign of your own feeling of value and can transfer into patients’ lack of confidence in the doctor.

3. Ignorance in Hiring:  It is valuable to have a prospective employee interview with someone else in addition to the doctor.  The additional interviews can even be done via telephone or Skype.  It is amazing what others may detect while interviewing.  Busy doctors may want to hire someone pre-trained from another doctor’s clinic.  Key question, “Why aren’t you still with Dr. Bob?”  You need to take the time to call their references and learn how to ask the right questions.  We all want to hear that the prospective employee is wonderful and could return to their previous job, if they wished.  However, do we really want an employee from another doctor’s office?  Are we taking on another doctor’s bad habits and preconceived ideas that may not click with ours? I believe an employee must have some fundamental qualifications, but I do not want to hire from another doctor’s office.  I want to indoctrinate my own employees.  I have found that personality testing can provide great insight into what motivates a person and makes an employee tick.

4. Hanging onto Employees: No one wants to let an employee go and, unless you are the only one left to do the job, delegate it to a reliable employee or even a spouse, if available. Along with the delegation to another should be instructions of exactly what to do and say.  The simpler the better and just saying while handing the employee a short, nice severance letter, “This was a decision recommended by the accountant or management” could be the best approach.   Keeping an employee because of your own fear—fear of time it takes to advertise and interview and the fear of the time it takes to train—can hold you hostage.  If you have even a “gut feeling” about an employee, you should monitor this feeling closely.  It can be amazing how statistics can improve when the wrong employee is out of your office.

5. No Standards or Controls:  How much deviation from your standards can you tolerate and how do you know?   Chiropractors offer healthcare services; so where do standards come into play?   You, personally, are a well-trained doctor and your care and reports are fine and up to standards. Yet, how about standards in your paperwork?  Do all your forms that are given to a patient look crisp and clean with your logo, address, telephone number and website address?  Is your website up to standard?  So many people now research using the internet and, if a page of your website is “Under Construction” or there are major misspellings and grammatical errors—let alone just darn hard to navigate—all this turns people away. Make and meet standards in your office appearance and employee appearance. If you don’t have any standards, how can you have any control?  Implement what you want to see in your office and, of utmost importance is to be clean, orderly and consistent from room to room and employee to employee.  The doctor must appear well-groomed and look like a doctor.  I believe in wearing a lab coat, dress shirt and a tie. This is a topic that merits much more dedicated interest by many doctors.

6.  Poor messaging:  This applies to the way both you and your staff communicate with your patients. Messaging starts with the first telephone call from the patient to the Report of Findings and then on to communicating with patients all the way through care.  You need to trim out the fluff and have a message that is focused and easily understood. Poor messaging also means not anticipating what information a patient needs to know.  As an example, during the first telephone inquiry, the majority of a patient’s questions should be answered prior to being asked.  Another way to message poorly is not distinctly branding yourself and your clinic as an expert. What you need to remember is, whether it is good or bad, we are marketing and branding ourselves every day in multiple ways.

7.  Confusion about who you work for:  Do you work for your patients or the insurance company?  Are you afraid to offer best healthcare practices rather than best insurance practices?  Why not work for the patient and place payment responsibility on the patient by having a cash-only practice.  This will do away with third-party billing and waiting for reimbursement of a discounted, contracted rate.  The cash-only model allows the doctor to receive fair and reasonable reimbursement, and it emphasizes that the contract is between patients and their insurance companies and not between their insurance companies and the doctor.  Patients understand it; they get it that insurance companies dictate care, slash fees and are not focusing on meeting the needs of the individual, unique patient.

These are all correctable traps and, with this being the start of 2011, you can start fresh.


Dr. Richard E. Busch III is a nationally recognized Doctor of Chiropractic, author, and speaker. He has successfully treated thousands of patients for chronic and severe disc conditions that traditionally would have required surgery.  Dr. Busch developed the DRS Protocol™, utilizing spinal decompression technology. He has served as a national consultant for the continuing development of this technology and the DRS Protocol™. Dr. Busch has published a recent eye-opening book *Surgery not Included: Freedom from Chronic Neck and Back Pain. You can visit his website at or or call 1-866-662-2225.

Begin With the End in Mind to Ensure Financial Ease
Practice Operations
Written by Kathy Mills Chang   
Friday, 21 January 2011 11:50


lmost every new patient encounter will begin with the phone call that potential new patient will make to schedule their initial visit.   Setting the financial tone of the relationship with that potential patient as early as the initial phone call lays the groundwork for a healthy partnership in the years to come. In the same manner that we might not go to the mall and purchase a new outfit without first taking a peek at the price tag, most new patients will want to know the costs associated with their care before they begin. Communicating this information effectively without scaring the patient away is a finely tuned dance that requires confidence, knowledge, and effortless ease.

We’re frequently asked, “How much do we talk about finances on the very first, new patient phone call?” The answers to this question are as varied as the reason for them. Some feel that any discussion of finances leads a potential new patient to believe that all we are worried about is the finances.  While we don’t want money to be the main focus of our list of questions for a potential new patient, some discussion of the finances is vital to ensure that your process is smooth and orderly. You must know if they plan to use some third party insurance to assist with payment of their bill. You really can’t answer the all important, “How much does it cost to see the doctor?” question if you don’t know about their insurance. We can apply patterns and our experience based on other, similar patients, but the truth is we never REALLY know until we verify the insurance.

By asking the patient, “Is there some type of insurance coverage you would like our assistance with?” we imply that our job is to assist, but the ultimate responsibility remains that of the patient. There may be certain responsibilities required of the office, such as mandatory billing for a program like Medicare, but setting this tone with a patient early on that you are assisting, and not being solely responsible, is most useful. While the conversation may naturally turn to questions about network participation, policies relative to noncovered services, or any cash discounts that you may offer, minimizing these on the telephone is preferred. It is helpful to have a "cheat sheet" at the front desk or near the phone to have standardized answers to some of the more difficult questions asked on a new patient phone call. Some commonly asked questions to be prepared for include:

Communicating this information effectively without scaring the patient away is a finely tuned dance that requires confidence, knowledge, and effortless ease.

"Does the doctor participate in my insurance network?”  If you do not participate, but offer other patient friendly payment plans, appropriate scripting will help ensure the appointment is secured.

“How much does it cost to see the doctor?": Knowing how to think on your feet and explain your fees whether cash or insurance, will ensure that the patient gets in for the first visit where you can explain in greater detail.

Verifying a patient's insurance benefits before they are seen by the doctor can significantly reduce financial concerns and confusion later. Sometimes this seems like a potential waste of time when they’re not even our patient yet.  The benefits far outweigh the negative effects of any potential time wasted if the patient does not come in for an initial visit. The ability to collect properly on a first visit because you have already verified the insurance lends itself to the very effective financial policies you are able to enforce on visit one.

Collecting on the first visit allows that patient to establish good financial habits and patterns with your office. Often, patients are used to the type of benefits their insurance may have in a primary care physician’s office, such as a flat copayment. Frequently, chiropractic benefits can be complicated and could even include patient responsibility for each and every different service rendered in the visit. Unless the patient has used these benefits before, it can create sticker shock. Therefore, when you are able to discuss benefits on the first visit, even in a limited way, you are further setting a great financial tone for that patient relationship.

It can seem like financial matters are the elephant in the middle of the room that nobody wants to talk about.

Many chiropractic practices use the procedure of explaining full benefits and patient financial responsibility on a subsequent visit after the doctor has laid out a treatment plan with the patient. This is the perfect time for a financial report of findings. Patients want to know what to expect in order to budget their expected financial contribution. Conducting this financial consultation is a tremendous habit to adopt. One of the primary reasons patients drop out of care is lack of a clear understanding of financial liability or the perceived inability to pay. Most practices have policies that allow the patient to make payments toward their responsibility and reinforcing this in a financial report of findings tends to keep the patient on track and not so ready to drop out over simple financial matters. The financial report of findings should include a review of the doctor's treatment plan, explanation of the patient's responsibility, and their options for making payments. Insuring that no one leaves this meeting without a clear understanding of that responsibility will go a long way toward laying a strong foundation with this patient.

It can seem like financial matters are the elephant in the middle of the room that nobody wants to talk about. However, the practice that addresses patient finances head on, in a matter-of-fact conversation, alleviates these concerns before they crop up. By discussing finances when the patient calls for their initial visit, at the first visit and again when laying out a treatment plan, the financial aspects of their treatment encounters in your office tend to not be a patient's primary concern. With their mind set on getting better and not focused on financial issues, the patient is a happy and productive practice member.


Kathy Mills Chang is the founder of her own consulting firm, assisting doctors with finding financial and reimbursement ease in practice and helping them to make and keep more money. She specializes in coding, documentation, Medicare, billing and collections and patient finances.  She can be reached for service and questions through her website at or by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

More $ from Uncle Sam
Practice Operations
Written by Paul B. Bindell, D.C.   
Tuesday, 18 January 2011 16:39


ur Federal government keeps coming up with ideas to give all of us more money!!! At least that is what they claim. If you use certified Electronic Health Record (EHR) computer software and demonstrate meaningful use of that EHR, then you may qualify for up to $44,000.00 in bonus payments from Medicare. The bonus is NOT based on the cost of the EHR program. The amount of the bonus is determined by the amount of money Medicare pays you. Medicare sets the bonus at about 75% of what they normally pay you. So if your annual Medicare payment is only $1,000 you will get a bonus check for $750; if the payment is $25,000, your bonus check will be $18,000. Should you qualify for the maximum bonus each year for 3 years in a row, your bonus checks will total $44,000.

In order to demonstrate meaningful use of your EHR system, you must utilize the Physicians Quality Reporting System (PQRS) codes. And according to the government, any doctor that uses the PQRS codes correctly will have his/her payments increased by 2%. This means that for every $100 you would normally receive from Medicare, you will get a total of $102 by using PQRS. It may not be a lot, but it is better in your pocket than staying with the government.

PQRS consists of codes that most of us have never heard of. There are CPT I codes, CPT II codes and G-codes. And each code must match up with something else on the claim form. That something else may be an ICD-9 code, a regular CPT service code, and/or some aspect of the patient’s demographics. Each PQRS code must have only one diagnosis pointer. And when PQRS is used, your CMS1500 must be completed in a very specific manner.

In order to demonstrate meaningful use of your EHR system, you must utilize the Physicians Quality Reporting Initiative.

The good news is that PQRS is being automated in some EHR systems. This programming development provides you with the benefits of PQRS without having to master every aspect of its technical requirements. However, you should make it a point to understand the concepts behind PQRS so that you will be able to respond to claims examiners or auditors when asked why you used it.

An example of the PQRS codes shows what needs to be reported regarding back pain. Back Pain Measures Group consists of 4 measure specifications:

1. PQRI measure #148 back pain initial visit–includes pain assessment, functional status (assessment form in patient file, signed by patient), history noting presence/absence warning signs, assessment of prior treatment and response, and employment status. Use CPT II code 1130F. The pain assessment and functional status should be completed by the patient using standard functional assessment forms such as Oswestry, Rand, Pain Disability Questionnaire, etc. Note that Medicare requires proof that the patient completed the form, so the patient’s signature MUST appear verifying that he/she answered each question and completed the form.

2. PQRI measure #149 back pain physical exam–straight leg raise test and a neurovascular exam showing presence/absence of findings. Be sure to note all positives and negatives. If you only record positive findings and do not record the negatives, an auditor will claim that you made a false or fraudulent claim. Use CPT II code 2040F.

3. PQRI measure #150 back pain advice for normal activities–advice to maintain or return to normal activities. Use CPT II code 4245F.

4. PQRI measure #151 back pain advice against bed rest–patient counseled against bed rest of 4 days or longer. Use CPT II code 4248F.

If ALL these items are to be reported, then a single composite G-code G8502 can be used. Note that PQRI codes must be reported correctly. If errors are made, you do not have the ability to correct them and simply loose the benefits of PQRI.

Currently there are 179 PQRS codes. It is incumbent on you to go through the list and see which ones apply to your practice. Make sure those items are in your EHR system. It is critical that you look up each code individually and know when it should/should not be used. Keep in mind that the PQRS codes are evaluated and revised every year, so from one year to the next you may need to revise your list.

Various software companies are passing the tests and getting their EHR systems certified.

The government has authorized 3 companies to test and certify EHR software. Many EHR programs are passing the tests and getting certified. The overwhelming majority are medical systems. There are a few Chiropractic specific EHR systems that received certification in November 2010. Only a handful of Chiropractic specific software companies qualified for certification before the end of 2010. And you had to have certified EHR in place before the end of 2010 to qualify for the Medicare stimulus calculation beginning in January 2011. Otherwise, the earliest you can qualify for the stimulus bonus is April 2011. So if you are planning on getting EHR computer software for your practice, find out if the system you are looking at is certified or will soon have certification. If it is not, then select another software program that is or will soon be certified.

Using PQRS is the tool that demonstrates meaningful use, and therefore qualifies you for up to $44,000.00 in bonus payments. It also gives you a 2% bonus just for using PQRS.

Make sure that you get the greatest amount of payment from the government that you possibly can. This will be one of the rare occasions when you will be able to recoup some of the money you paid to the tax man.


Dr. Paul Bindell, a 1975 Palmer graduate, has been in practice in Rockaway, NJ, since 1976. He lectured on Chiropractic in Brazil and Israel and is a past Chairman of Public Relations for the Northern (NJ) Counties Chiropractic Society. The Chiropractic Answer produced by Dr. Bindell in the 1980’s was a cable television program, a newsletter, and a newspaper column.  In 1991, Dr. Bindell and his family began Life Systems Software so Chiropractors would have computer programs based on real practice. As a consultant, Dr Bindell is the expert in assisting the profession and individual Chiropractors to improve and succeed. Numerous articles have been written by Dr. Bindell and have appeared in several Chiropractic journals. Dr. Bindell is available to speak to your group or organization and can be reached by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or you can call Life Systems Software at 1-800-543-3001.


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