can honestly say, after 27 years in practice, there has never been a better time to start a career in Chiropractic. Even with national healthcare reform moving forward, you can build a practice of your dreams by following some simple rules and taking time to look before you leap.

 

It was President Ronald Regan who said, “Trust, but verify,” and it is still good advice today. You have so many things to consider in opening or joining a practice. Do not let the excitement of getting into practice lead you into making decisions that you may later regret. Take time to complete a careful review of associate agreements, building and equipment leases and provider agreements. Before you sign anything or join an existing practice, use your head and seek wise counsel from trusted colleagues and/or legal counsel. Never just take someone’s word for what you should and should not do, can and cannot do when it comes to running your practice or what is acceptable in operating a practice. This is not meant to be harsh toward those with good intentions who are offering advice to help you succeed, but it is meant to encourage you to protect your license to practice. As a medical compliance specialist, I  have seen far too many cases where a doctor is facing fines and penalties and their only defense is, “Well, my buddy said it was okay and he does it all the time,” or “I heard my board of examiners said it was okay.” Verify what you hear about your state’s rules and regulations with your board of examiners, your state association, a trusted consultant, or established colleague with an impeccable reputation. When possible get verification in writing. This is most important when it comes to billing, coding, documentation and financial policy. Why? Because signing a bad lease can surely cost you money and aggravation. But improper billing, coding, documentation or faulty financial policies that lead to dual fee schedules or inducement violations can cause you serious financial harm, or worse, can cause you to lose your license. Game over. 

 
2. Never forget, your license is a privilege to practice… not a right.
Despite the years and thousands of hours devoted to completing chiropractic college and for some, hundreds of thousands of dollars spent, never forget, your license to practice is not a right but a privilege. And like any privilege, it can be taken away. Your license is extremely valuable and should be treated as such. Do not jeopardize your license by engaging in or participating in poor business practices or joining a practice that can clearly put you at risk. Violating rules and regulations from your Board of Examiners is bad enough, but the risks do not stop there. Make sure that your new practice, or the practice you join, is in compliance at all levels, from your State Board of Chiropractic Examiners or other licensing boards to the Department of Insurance for your state. Also, consider the rules and regulations from your Provider Agreements, State and Federal Anti-kickback Statutes, the Centers for Medicare and Medicaid (CMS/Medicare) and the Office of Inspector General (OIG). While this may seem overwhelming, it really is not that hard to accomplish with the proper guidance. If and when you find there are rules that conflict, and they do at times, take the safest and most conservative approach in determining your policy and document in your compliance manual what your decision was based on. Again, protect your license. It is, in essence, your passport for life to prosperity, so guard it carefully.

3. Remember, times are never good or bad, they are just different.
You may have heard of the Mercedes ‘80s, a time when you could put anything on an insurance claim form, send it in, and a check appeared. Or perhaps you have heard the horror stories of managed care where only two visits were permitted by an insurance carrier. Having practiced through these times, as you might imagine, the truth lies somewhere in between. Never was it that easy in the 1980s, and if you documented properly to support medical necessity, rarely would you be limited to two visits. What is clear and beyond debate now is that you are entering practice at a time where all professions, including chiropractic, are under more scrutiny than ever before. There are more fraud and abuse investigations now than at any other time in history. Billions of dollars are being recouped by the federal government and insurance companies for fraudulent claims. It has been reported that the Office of Inspector General stated that for every dollar spent in healthcare fraud and abuse investigations, they recoup $17.00. So, do not look for audits to decrease; they are making money. Unfortunately, some of the scrutiny in chiropractic is warranted, and it will continue. My intent is not to instill fear, but to empower you with facts so you can minimize the risks of audits, fines and penalties and practice with some peace of mind.

Here is the UPSIDE!

Again, protect your license. It is, in essence, your passport for life to prosperity, so guard it carefully.

More doctors are taking a look at their billing, coding and documentation and are taking steps to be more compliant with all the layers of regulations. Make sure you start off the right way by knowing and following the rules. If you are joining an existing practice, make sure you know they are aware of the rules and regulations and are proactive in making sure they are running their practice in a compliant fashion. I can tell you, far too many docs like me who have been practicing for many years ignore the fact that the rules have changed, and we must change. If you run into a great opportunity to join a practice, but the doc’s head is in the sand, use the opportunity to help them bring needed change to their practices if they are open to it. If they are not, then it is simply not in your best interest to join that practice.

4. Know how joining an existing practice can put you at risk.
When you treat a patient, whether in your own practice or not, you have an NPI number that is recorded on the claim form. The NPI identifies you as the treating/ordering doctor. Even if someone else owns the clinic, your NPI is on the claim form and you are responsible and accountable for what is on the claim form. Box 31 of the CMS 1500 form is an attestation that the information is accurate, and you agree to the statements on the reverse side of the form, including:

I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations.

So whether you are personally responsible for sending out the claims or not, you are held responsible because you have allowed them to use your NPI number as the treating/ordering doctor, and you are at risk if the practice is not operating in a compliant fashion.

5. Look and ask before you leap.
If you have decided to join an existing practice, even the family practice, there are things to consider and respectfully ask about before signing on. Yes, it is okay to ask questions of mom and dad or other family members. As a second generation chiropractor who did, I can tell you it may not be easy, but you have a right and an obligation to know some key things about the practice. Here is a short list:

• Do you have sound financial and billing policies in writing? Ask for a copy and review them.

• Is there more than one fee schedule? If so, why? And is it legal? In some states, charging more to insurance patients than you do for cash patients is considered a “dual fee schedule” and could be illegal. Ideally, there should be one fee schedule. One of the safest policies is to only offer discounts when they are part of a written financial policy, which could include contractual or network discounts, mandated fees like those established by Medicare, or when there is a documented financial hardship. Other legal discounts could include a defensible time of service or prompt payment discount, if and only if permitted in your state. If you would like a copy of a simple, one page financial policy that is rock solid, send an email to This e-mail address is being protected from spambots. You need JavaScript enabled to view it and put FORM in the subject line.

• Does the clinic up code, or down code based on the type of insurance coverage? Meaning, do they bill a higher level of Evaluation & Management code for PI or Worker’s Compensation cases and a low-level code just because they are cash patients?

• Do you waive deductibles or co-payments? This is clearly a violation of rules and regulations and most provider agreements unless a true financial hardship is established by the clinic.

• Do you have a written financial policy that is covered with patients? Many complaints to Boards of Examiners seem to be triggered by a poor financial policy, which is easily eliminated by written policy.

• Does the clinic have a compliance plan in place to minimize the potential for fraud and abuse and to ensure compliance with all layers of regulations? There are many steps that can be taken today to minimize the potential for audits and mitigate potential fines and penalties.

• Has the practice ever been audited? If so, what was the outcome? Today, it is not a matter of if you will be audited, but when. And, keep in mind, just because there has been an audit does not mean someone did something wrong. It could just be their number came up.

Finally, despite what seems like a list of overwhelming decisions and concerns, you are embarking on a career as a doctor of chiropractic at a time that has opportunities like we have never seen before. Expect the best, give your best to the profession and your patients, and you will not be disappointed.

Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as  president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a  Fellow of the International College of Chiropractic. He founded ConservaCareCorp, the first chiropractic network selected by the State of Mississippi to serve over 195K covered lives in the State Health Plan. You can contact Dr. Foxworth at 1-888-719-9990, This e-mail address is being protected from spambots. You need JavaScript enabled to view it or visit the ChiroHealthUSA website at www.chirohealthusa.com

aving been in business for over 40 years and franchising for over a decade, I often get asked why would anyone buy a franchise when they could just open their own business.  They will then go on to tell me about some friend or relative who invested a lot of money in a franchise just to lose it all or have the franchise go out of business.  These are usually people who have no concept of what it takes to start a business and have not done any research on franchises. The facts speak for themselves; when you look at the statistical data provided by FranFinders, franchise consulting group, franchise businesses account for nearly 50% of all retail sales in the U.S. Franchise businesses employ more than 14 million Americans, with an estimated 5,000 franchise concepts in 75 different industry categories.  To be even more concise, 1 out of every 12 businesses in the U.S. is a franchise and total sales for franchise businesses are approximately 2 trillion dollars annually. 

 

Even though you may hear reports of franchises closing in the media, the fact is that from 1971–1997, less than 5% of franchise businesses closed each year.  A study conducted by the U.S. chamber of commerce found that 95% of franchises are still in business after 5 years, compared to just 47% of self-launching businesses.  Buying a franchise more than doubles your chances to survive as a business owner, and by choosing the right franchise your likelihood for success can be greatly improved. So how do you choose the right franchise for you? Do you jump on the latest and fastest growing hot trends, or do you go with an older more established company everyone knows and that has a strong brand identity?  Would you rather stay in your comfort zone and do something in a field you are more familiar with?  Do you want a big business, small business, home based, or the chance to have multiple locations? What is the size of the market and how strong is the franchisor? The truth is, the reason most franchisors are successful comes down to just several things. First, the business model has proven to be successful and profitable and has the history and data to prove it is sustainable and not just a fad. Next, the franchisor is always striving to provide its franchisees with the best possible business tools to support them in all areas of the franchise business. 

The strongest franchise companies will take the time and money to reinvest in supporting their franchisees and develop ways to open communication and listen to their community. A good franchisor will make decisions that benefit all its franchisees equally, greatly increasing your chances for success. So back to the question, should you jump on the hot new franchise concept or not? Do so only if you believe and can prove it is sustainable and the franchisor has the support systems in place to help you while building a strong brand.

Sometimes, new franchisors cannot grow or react fast enough to support their rapidly growing network. It takes a great deal of time and a good management team to create, develop and implement new, strong systems and establish a positive brand image all at once. However, if you are one of the first franchises and the brand explodes, the equity and value of your franchise could be huge in the future. Do your research carefully on new franchise concepts and talk to as many existing franchise owners as possible asking for their candid opinion on how the franchisor is handling their growth. More established franchise companies should look and feel like well-oiled machines and provide you the greatest chance for success, but often times it is hard to find good new locations and territories when the brand has been around for a while. Established franchise concepts can also be considerably more expensive because the brand has grown and become more valuable.

Do you want to stay in your comfort zone? If the franchise culture doesn’t mesh with your personality, then your chance of success could be greatly reduced. If it requires a certain skill set like a strong sales background, and you don’t enjoy sales, don’t do it. If you are already trained in or are familiar with the franchise concept you are looking at, all the better. The franchisor will then just need to train you on their systems and culture and give you the tools to market and manage your business. No matter if you wish to have a small, home based franchise or a larger more established franchise, the process is the same. Do your homework; there is a saying in franchising— when you buy a franchise, you are in business for yourself but not by yourself.

Before buying any franchise, a visit to the corporate office for a discovery day to meet all the different departments you should have at your disposal, is a must. Initially, you will incur the cost of a licensing fee which gives you the right to learn the systems, use the name, logos and intellectual properties developed by the franchisor and provide you with extensive training on the model and its systems. On an ongoing basis, you may also be paying a royalty fee back to the company to help support you and your franchise business. Always know what support is available to you and use it. That is what your royalties are for.

So if you think you can own a franchise and have control over the offer, message, pricing, look, and logos then franchising is not for you.

With over 5,000 different franchises to choose from, you can take your time. You should never purchase a franchise you’re not certain about and the decision should be yours alone and never left to a salesperson or broker. I truly believe that buying a franchise is a wonderful way for first time business owners to learn many of the basic business skills they can use the rest of their lives. Marketing, accounting, time management, information technology, vendor relations, real estate, the list goes on. For those who are more experienced, many franchise companies have area or regional developers who represent and support a group of franchisees in a certain geographical area. Regional developers are franchisees who buy the right to sell, develop and oversee a defined geographic area and must be well-trained on the model and operating systems. They not only represent the franchisor’s interest, but also the franchisee’s.

I believe that franchising definitely gives you the greatest chance for success, but I also know that franchising isn’t for everyone. Franchisors must protect their brand identity, story and image at all costs. So if you think you can own a franchise and have control over the offer, message, pricing, look, and logos then franchising is not for you. Franchising encourages entrepreneurial spirit but only to a point. A good franchisor will not allow franchisees to do their own thing as it will ultimately dilute the value of the brand for all who have invested in it. A good franchisor will have a feedback system already in place so they can listen and learn from their franchising community. This may include a franchise advisory board, focus group, steering committees, annual conferences and a help desk. Take your time, make the calls, visit the locations, ask for the latest up to date franchise disclosure document (FDD) that every franchisor is required to provide you and don’t forget to make that trip to visit the corporate office. The FDD will provide you with all the legal information about the franchisor. Franchisors are legally required to update their FDD each year with a current list of open, closed, and transferred franchises as well as a corporate audited financial statement required by the U.S. Security and Exchange Commission (SEC). The FDD will also contain estimated opening costs and in some cases earning claims for the average franchise and the highest and lowest producing units.

Finally, if you have made the decision that a franchise is a good fit for you, have a qualified franchise attorney review the FDD as well as the franchise agreement to be certain you understand every fee you will be required to pay as well as your obligation to the franchise and the franchisor’s obligation to you. Owning a franchise can be a wonderful partnership with the right franchisor and create great relationships with your fellow franchise owners, with whom you share a common bond. In addition to making a good living, you can build value and equity in your business enabling you to someday sell it or pass it down. Just do your homework and enjoy the experience— it could reward you for a lifetime!


John Leonesio is a recognized expert in the health, wellness and franchise industry. He is the CEO of The Joint…the chiropractic place . He co-founded Scandinavian Health Spas, growing it from one club to 40 clubs. In 1990, he founded The Q, the Sports Club, growing it to 20 units before selling to 24 Hour Fitness. In 2002, Leonesio founded Massage Envy.  In just 6 years, he took it from concept to a $300 million operation with more than 800 licenses awarded.