Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 92 I
"Get Paid in 2013 and Beyond"
In 1988, I had been in practice for 6 years. I had a home office, had just completed an expansion and was thriving with 1300 square feet of office space and 2 staff members. I was treating approximately 350 patients per week and with a 30% overhead, the profit margin was great. Since I was within 1 mile of the largest institution on Long Island, The State University of New York at Stony Brook, this was my #1 source of patients. There were over 40,000 students and workers within the university system and they predominantly had Empire Blue Cross Blue Shield. The policy paid 80% of the usual and customary fees and life was simple; treat, send a bill and within 45 days, the check came. Then the bottom fell out.
What I didn't know at 32 years old (I was extremely naive) was that managed care was imminent and although I had heard rumors, I kept my head in the sand because life was so good and I was such a good healer and an innate system would provide. It did provide...a lesson in life that has stuck with me for 30 years.
One day we opened up the mail expecting a slew of checks and instead we got blanket denials stating that we were not in-network on 100% of our Empire patients which equated to 80% of our practice. I attempted to become an in-network provider, but the president of the state organization had cut a deal with Empire, became their highly paid consultant and only allowed his favorites within the state organization to become in-network providers. Since I was not involved politically, I had no idea and I was out...for years. When we tried to convert those Empire patients to cash, we retained almost ZERO. All of those patients that loved me went to in-network providers and I had to reinvent my practice.
Today, we are coming to the same crossroad according to every economic, legislative and political indicator nationally I have come across. The only difference is that you are on the INSIDE and can plan ahead and be prepared. If you don't, I fear you will find yourself in the same position I was in 1988. Will it be tomorrow, next month, next year or beyond? In New York, it was December 1, 2010, in New Jersey, it is next Tuesday, in your state it is already happening at many levels, including, but not limited to, peer reviews, IMEs and carrier denials. The next step will be legislation nationally because the carriers have found a way to deny your claims that is legally defensible.
Over the last few years, you have been hearing and reading about "evidence-based care," but not fully understanding its impact on everyday practice. Many of you have kept your heads in the sand on this issue, claiming it's not about the evidence, it's about either turning life on, rendering YOUR best decisions based upon your experience or any other level of rhetoric you choose to either rationalize or ignore this issue. Many of you also believe that your documentation is strong, proving necessity and have spent $1,000's on EMR systems that claim to have every possibility covered. (They don't.) Those days are over. You have 2 choices; follow my suggestions or forever complain as to why everyone but you gets paid.
The real issue is one of "hard evidence" that will affect you for years to come. In December, 2010, the New York State Workers Compensation Board enacted the first regulations nationally to mandate evidence-based proof in the form of a peer-reviewed published article in a scientific journal to go beyond the "very few visits" afforded to the injured in the guidelines. The prime reason New York enacted the regulation is that the #1 insurer of workers compensation patients in New York is the State Insurance Fund and is owned by the State of New York. The state, as a result, has a "vested interest" in increasing profits for itself. Therefore, the legislators were very amenable to using these "first-ever" measures to curtail spending, albeit at the expense of the injured and the doctors caring for them. This is in a state that is already the lowest compensable state nationally despite being ranked as one of the most costly states to live in. The entire process is fraught with problems that have already negatively affected the people of the State of New York.
It took 2 years and now New Jersey has enacted not regulatory, but legislative changes that are far more sweeping and potentially more devastating to the lives of the people in the State of New Jersey. In addition, it has set the foundation for what I am sure will sweep the nation, creating the first legislation to be enacted and potentially increase the profit margins of the carriers. To be clear, this WILL increase the carriers already large profit margin, in spite of the carriers disproven rhetoric of losing money according to the trial lawyers who feverishly fought against this bill. However, political lobbying and campaign support ($$$) sway opinions, spin truths, pervert statistics and buy votes at the legislative level.
The following is the exact language in the new Jersey law that is specific for personal injury cases. I am certain this will be the standard nationally as carriers (W/C, PI and managed care) in many states have already adopted this standard in many forms in their contracts. If you are prepared for this level of documentation, you will prosper with everyone else complaining and many going out of business.
N.J.S.A. 39:6A-4a provides that the Commissioner, in consultation with the Commissioner of the Department of Health and Human Services and the applicable licensing boards, may reject the use of protocols, standards and practices or lists of diagnostic tests set by any organization deemed not to have standing or general recognition by the provider community or applicable licensing boards. Although the Department is not adding to the list of rejected protocols, the Department is proposing to add a definition of standard professional treatment protocols to guide the acceptable evidence of standing or general recognition for a specific medical procedure or test. These are defined as evidence-based, clinical guidelines published in peer-reviewed journals. The Department has become aware that the medical necessity of a procedure or test is being supported by articles, books and practice or treatment guidelines that are published by the proponents of the treatment or test in journals that are not peer-reviewed and where the evidence supporting the treatment or test is anecdotal. These types of treatment protocols and guidelines cannot be used as evidence that a treatment or test is medically necessary.
The definition is so narrow that there is little room for a doctor to find innovative ways to care for patients who do not fit into the reported mold and will now suffer. We have yet to realize all that is possible to help the sick. Personally, I believe this is the most disgusting way to make money...even for the carriers. People will die and suffer because of this law. I wish everything bad on those lawmakers that voted for this law and for the carriers that lobbied for it as well. They should get an illness that needs a non-published solution because the journals have not yet caught up to the trial and errors that are the innovations in medicine that can help them! I am MAD, disappointed and really pissed off!
With that being said, beyond my emotional reaction and ranting, there is a way to maximize your success in this model. The solution is relatively simple and in our musculoskeletal world, there is much already published to support what we do in most circumstances. The answer is EVIDENCE. Over the last 4 years, we have been publishing bi-monthly fliers to hand out to lawyers with references. Much of what we do is based in research and can be found in those publications and it is FREE to you as part of the Lawyers PI Program. However, there is too much missing that pertains to treatment. The bi-monthly fliers are centered in diagnostics and you need research for your care.
#1 Cost: $0.00 and then $1000's
You need to do a literature search for every procedure. This involves either going to either Google Scholar, PubMed or Ovid, finding pertinent articles, reading all of the abstracts and then purchasing the specific articles to support your procedures. Then create paragraphs or macros to plug into your EMR system or cut and paste into your SOAP notes.The process is simple, but a requirement to prepare for the present and future and the cost is your time and the cost of the articles that range from $0.00 to $60.00 per article.
#2 Cost $1.81 per day
EMR Macros Program
Understanding years ago that we were headed in this direction, but not realizing the sweeping necessity and impact of research pertaining to reimbursements, we created a program to search over 20,000 journals monthly to find specific research that supports the necessity of your treatment. Currently, there are over 200 individual macros that handle most treatment issues. The list grows as participating doctors' needs grow. Should any member of the program need a new macro, he/she makes a request and we search the journals to support that need and create a new macro to support the procedure. The program is created for the future needs of practice, while supporting today's needs for proof via published peer-reviewed journal articles. The cost of the program is $1.81 per day, $55 per month, billed at $660 yearly and can be gotten at http://emrmacros.com/. This program supports all EMR systems as you can cut and paste them into your current program through "the customizing macro abilities" within those systems.
#3 Cost: $149 monthly
We have also partnered with an electronic medical record (EMR) company, Software Motif which is a cloud-based system, meaning that you need no hardware or software beyond your current computer and is accessed via a Web site. After an exhaustive review of the most popular (and some not so popular) EMR systems, we chose this as we have been following it for over 4 years. It is a simple system that is devoid of the fancy graphics and nonsense that often creates the sale of the more expensive, but less effective, EMR systems. However, this program renders perhaps the finest reports I have seen to date. It also has the most advanced "random word" generator I have worked with in the industry.
In addition, the above EMR macros are included in the price of Software Motif, as they are already populated into the software. To make it work in Software Motif, you simply "click and drag" the appropriate macro into your note or report. The cost of the entire cloud-based system is $149 monthly (including the EMR macro program) compared to the cost of the most popular chiropractic management software that ranges between $11,000 - $15,000 plus a $1500(+) yearly support fee, plus advanced hardware costs to support the computing.
To get Software Motif, call 1-800-481-9060 and ask to set up a demonstration.
#4 Cost: Everything
Do nothing, stay the course and hope that an innate system will provide.
YOU MUST PICK 1 OF THE ABOVE 4.
THERE ARE NO OTHER CHOICES.
Here we go again:
Some of you will be thrilled with this knowledge and be proactive in protecting your practice and future finances. Others will have no need to make any changes as your business infrastructure already has these well-handled because you heeded our advice already. The rest of you will practice "failure technology " and complain you want the services, but: 1) don't understand why you have to do more work, 2)why being a "healer" isn't good enough, 3) that we should do all of this for you for free and can't wrap your head around the fact that we have to put time and money into making this work for you. In this case, it has been years of research and programming to get to this point.
I just thought I would save you the time "bitching" to me in a subsequent e-mail. I got it!!!
The future is clear and the path has now been simplified with solutions to succeed. DO NOT procrastinate as this is happening very quickly and will cost you dearly if you do not start preparing right now. I want to leave you with the legislative definition which I am certain will be the prevailing language nationally over a short amount of time:
These are defined as evidence-based, clinical guidelines published in peer-reviewed journals.