Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 1108
Lawyers and Medical 62 L

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

"I am meeting with a neurosurgeon, what do I say?""


Dr Studin: So tell me what's going on from the beginning.

Guest Doctor: I was approached by a group that I guess buys out a neurosurgeon surgery. A neurosurgeon, is now taking letters of protection and this group kind of like the one that I guess you work will pay up front for surgeries. The neurosurgeon said he was looking for a chiropractor. The company that's doing this reached out to I guess to many attorneys or at least one and they recommended my name to work with and I know the neurosurgeon.

Dr Studin: Let's just do a little bit of the blanks from a previous conversation on this. So there's a funding company also called the factoring company, which pre funds surgeries, they reached out to a surgical group. And in your region there is a very well known large chiropractic group. The surgeon doesn't want to work with them, but when your name came up, there was no objection, which means that obviously something you're doing right based upon, spending the last seven years building your credentials and your reputation, so your reputation proceeded you into being invited into this potential relationship. Is that accurate?

Guest Doctor: Yes. Just like when I started working with you.

Dr Studin: Now, with that being said, your reputation proceeded you. So now they're running after you. Now here’s the two wild cards. The wild card is number one. What is the factory company is going to pay you? Now remember historically they pay 30 to 35% the chiropractic if you told Bill. Now, I'm not saying that this is going to happen in this case.

Guest Doctor: Let me interrupt you for one second. He's not buying my LOP, my LOPs are going to be my LOPs. It's more like he's cherry picking the surgical cases and he also does the MRIs.

Dr Studin: So the funding company's going make their money from the surgeon, the MRI, you get to run your LOP to the end, just like always, which is wonderful. Now with that being said, you have a meeting coming up with the surgeon?

Guest Doctor: Yes. Well we had one, he wasn't able to make it to dinner and he's going to be giving me a call today.

Dr Studin: So in another words, you had a meeting with the lawyer or the funding company. Which one?

Guest Doctor: The funding company and the manager of the MRI facility.

Dr Studin: Okay, So you haven't met the surgeon yet. So the question on the table is, what do you say to the surgeon? Correct?

Guest Doctor: Yeah. I mean I know what to say. I just want to know what to say in the beginning. Tell me.

Dr Studin: This is the question on the table. What do you believe is the right thing to say to the surgeon and I might tell you I agree with you or disagree with you.

Guest Doctor: All right. Well, I just wouldn't tell him kind of like we talked about before, how I work a case up and triage and I can be kind of prescreening surgical cases for him. Although speaking to the funding company, they may want most of the cases to go to the neurosurgeon cause that's how they're going Market to the attorneys that I'm going to work them up, triage them properly. And then the next step would be the surgical referral and he's going to document whether they need injections or surgery.

Dr Studin: You have to be careful because what you just told me it could cost you your license.

Guest Doctor: Right, I understand. So that's what I want to, that's what this phone call is about.

Dr Studin: What you just said to me is the funding company, once they send you to prescreen the patient, but they're going to go to this surgeon anyhow. So the issue is, if it's not clinically indicated, why would they go to the surgeon? That's the part that could cost you your license to make this funding company rich. Now, with that being said, you should sit and chat with the surgeon and say the following I have a relationship with a lot of attorneys in the community. the Funding company did reach out to me, but I'm not taking their money. And that's important.

Guest Doctor: I think we have a little misconception. It's more along the lines of they have relationships with attorneys. They are not feeding me the patients, they're just saying, hey look, doctor Khan and Dr Pollock are going to be working closely together and he has some relationships that'll help, maybe get me referrals just naturally supposed to be natural and then whatever naturally goes to the neurosurgeon now.

Dr Studin: I feel better right now. You could say, listen, we have a lot of common relationships with the MRI companies, with the attorneys and the Funding company. I want you to know that, I don't really have a relationship with the funding company. It's just the legal community and they suggest that we get together and work. I just want to share with you, how I manage, use the word manage. Not Triage, and you could say, when I get a case and there's there any significant radicular pathic or myelopathic opponents. It's immediate MRI before we treat. If there's any compromise to the root of the cord, they're immediately off to you, to Tacoma. It's really that simple. If there's no insult to the route of cord, there's no reason to send them to you, then I just manage them. What I do, what I've been doing or how I've been trained that I've been trained through the state University of New York, Buffalo School of medicine on a MRI, spine interpretation, spinal biomechanical engineering, triaging the injured soft tissue pathology. I've a connective tissue pathology. I've been trained in all that stuff. There's SUNY Buffalo Medical School I've been trained to work closely with neurosurgeons. Does it matter of fact in many parts of the country, including here in Connecticut? Chiropractic with my credentials, are working closely with surgeons to triage their cases to keep the obvious nonsurgical cases out of their office so we don't have to waste your time on triaging a nonsurgical case. Unless it's within your business plan to triage every case. We do technology, we make sure we get a stir there. We make sure we get at least two or three clean slices through the disk, not catching the bone. And we get neuro to co-read. I read my own images and if anything is on the quarter route, it's yours. If it's not on the quarter route, usually I don't refer them out unless you want to see those patients also.

Guest Doctor: That was my question.

Dr Studin: Unless that's part of your triage plan also don't use business plan and I know you don't really know me or have confidence in me, but I'd love to work with you because I'm looking for something a little bit different for someone a little bit different and all of a sudden he can say what's wrong with the other ones? So tell me what's wrong with the other? who you've been working with? What's wrong with them?

Guest Doctor: I don't think there's anything wrong with all the surgeries I sent to them just between you and me, I don’t want to say to him, he does a good surgery. He doesn't do letters of protection and his documentation maybe doesn't talk too much about causality.

Dr Studin: Here's the issue. It's not working with them because they don't do letters of protection. It's simple.

Guest Doctor: If he asks do I want to say you, can I ask him or tell him there's one thing I want to say for him they don’t know how to comment on causality of created disks or language?

Dr Studin: Not really, there's two reasons why we're working with the other surgeon. One, us doesn't take letters of protection, but number two in his report, he doesn't causally relate the disc for the trauma and that becomes problematic because I feel it's clinically inappropriate, my reports are at odds with the surgeons and I'm not looking to make a case for the lawyer, but I have to honestly report and some surgeons just refuse to engage at that level at any level because they don't want to get involved with a lawyer, a good portion of my practice is trauma care and how many neurosurgical referreals do you refer out?

Guest Doctor: One a month probably. I mean too.

Dr Studin: Listen, that's a good number. You can tell them listen I worked with a physiatrist doing pain management. How many of you sending him a month?

Guest doctor: I sent them out 10/12.

Dr Studin: I'm just sending the pain management doctor, 10 to 12 a month to end up in the neurosurgeon's office every month.. Independent of this relationship. That's what I'm going to start doing with you. But if you want to start doing more of those pain management, if you want to do those procedures…

Guest Doctor: I don't know if he owns a surgical center or something like that.

Dr Studin: But listen to me carefully. Do you want to start doing those pain management procedures? we start creating a relationship at this level. I'm happy to send them all to you. Just put it out there.

Guest Doctor: Yes. And I will as long as it's a two-way street. He started marketing self as in personal injury.

Dr Studin: As long as we have the referral relationship, I'm going to send them all to you. So, he has the 12 pain management every month and at least two surgical referrals that you want. When I send a surgical referral to a neurosurgeon, based upon my understanding and reading the MRI and looking for motor deficits. You know when I see a motor deficit in the quarter, root compression, they're going to be surgery. So the surgery, the referrals I sent to you, 95% of them are going to need surgery. It's not like I'm sending you to the screen, I'm sending you to surgical cases. I've already been trained at all that stuff.

Guest Doctor: now, one other question. On the other side. What about psychiatric that I work now? that may all of a sudden get caught off. I just got to tell him it's a business decision.

Dr Studin: How many patients is the physiatrist were sent to you?

Guest Doctor: He's in a different town. He'd take letters of protection. Well, once in a while I get one or two.

Dr Studin: How many a year?

Guest Doctor: Five, but he does what he can.

Dr Studin: Send them one, two every now and if it's this guy sending you two, three, four, five, six every month and that guy is sending you five a year. The five years cut off. It's not your fault he doesn't send you and who cares whether they're two towns away or 20 towns away. Bottom line is you can't pay for a referral they are illegal, your commodity in your practice are your referrals.

Dr Studin: What currency are you getting in exchange and currency is in the form of referrals. The answer is nothing. That's the life of your practice. You refer to him cause he's a good guy. He refers to you cause you're a good guy. You're a good guy and you're not getting the referrals.I don't care that he can, I don't care if you like them. I don't care if he takes you to ball games. I don't care if he rubs your back with the Jeanie Rub. I don't care what he does. Your practice cannot sustain without referrals from disparate sources. And it's business. It's cold, hard business, Nothing else.

Guest Doctor: I don’t want to end things on bad terms or anything like that.

Dr Studin: You don’t have to end things on bad terms, throw them a bone every now and then send them a referral, if this neurosurgeon is going to be cross referring with you, why in God's name would you not feed him if he's sending you could send him 10 more. But they happened to be in the form of pain management. At every step of the way, just saying we've talked about while ago with staff. In the beginning you want to be nice. You want to be their friends and then you realize you can't be this friend and they'll always take advantage. You got to toughen up and then when you tough enough all of a sudden they'll change their relationship with you. They'll actually work harder. We went through 64 front desk cause we always have three front desk people in our office. Three full time. We went through 64 in one year, we just couldn't find the right person, but we went to hallmark and got a car that's said good luck in your next job. So well by the same token, I did have another staff member who stayed with me for 17 years. They are indispensable pieces that are dispensable or dispensable pieces that are indispensable. That's the same thing with this physiatrist. You're sending out, you're given him a lot. How much is a procedure?

Guest Doctor: When it is inicial we keep it low but like maybe around $300, $250 and I don't know what his procedures are.

Dr Studin: So he'll probably make about $1500 a patient because he does multiple procedures, right?

Guest Doctor: Yeah, I would say probably average.

Dr Studin: So you're sending him a month…

Guest doctor: $200,000 a year maybe.

Dr Studin: Something like that. That's the point. You're sending them a ton of money. Does even take you out for dinner?

Guest Doctor: He's offered me a lot of things to go play golf here to go to there to I just don't do that.

Guest Doctor: So let me do this to recap when I speak to the neurosurgeon, I just explain to them the way I manage patients and kind of tell them the numbers and then just ask him if it's within your practice model to see everything I should say.

Dr Studin: Is it in your practice models? You don't really know me or have confidence in me, but that's where you going to get into that in the beginning, managing the cases important. But you've got to get into, I've been trained through SUNY buffalo medical school on MRI, spine interpretation, spinal biomechanical engineering. He loves spinal biomechanics. You get are triaging the injury and I've been trained in all that stuff. So basically I've been trained to be you without the knife. Meaning I know when there's a surgical case or not, we're going to look for significant motor loss. If I see a motor loss and a significant approximation of the quarter route, especially if those are compression, I ain't touching them. If there's any kind of space occupying lesion. Other than that, if there's a disk and it's not really bothering the quarter of the route and motors pretty much intact, what am I sending him to you for? It's a waste of your time. I rather you spend more time in the operating room that's my philosophy and that's what's been going on around the country and in the state of Connecticut as well because Kevin Sedowsky is doing it up in MCL and he's doing it at a very high level.

Guest doctor: Doing what?

Dr Studin: Triaging for the surgeons. he actually working with the emergency rooms and all that other stuff, but not as a nurse practitioner but as a chiropractor. All over the country it's happening.

Guest Doctor: He owns or maybe part owner in something. Even if I say I just had to ask him if he wants, because it's asking to be once those cases because so he may have invested in other things. So if he wants to pay mentoring, I said yes and do those too. Somebody's still complaining of pain.

Dr Studin: Tell him, listen, get into the numbers. Right now, on average, I'm referring to about two surgeries a month the surgeons and when I say referring surgeries, they end up being surgeries cause there's quarter root compression and motor loss. So they're being operated on, they're being prescreen. But I'm also sending 10 to 12 pain management cases a month beyond that and if you want to do those, I'll send them to you. Dr Shatty does the lumbar pain management, but he doesn't do cervical. So he might say, it all depends, you've got to find out what this guy does. But do you understand how the whole process works now?

Guest Doctor: I do. Thank you. 

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