Perception: Large numbers of consumers and investigators alike believe that fraudulent activity in the Chiropractic profession is pervasive, and, unfortunately, may use a broad-brush to paint all chiropractors as deviant actors.
Why is the foregoing impression so prevalent today?
Is this perception the result of historical context, viz., that the foundational premise of Chiropractic was the Chiropractic-subluxation, a condition neither objectively identifiable nor proven to exist?
The subluxation may have something to do with the prevailing perception of Chiropractic. However, based on more than twenty years of experience investigating chiropractic fraud and assisting chiropractors with compliance, I suspect the following activity by some chiropractors may form the actual basis of such a perception:
-Do you want what I have?: Employ practice activity advocated by practice building consultants who boast of having large bank-accounts, expensive cars, pricey clothing, luxurious vacations... and the keys to practice success. Large numbers of chiropractors are recruited directly from chiropractic colleges.
-Recipe for Wealth: Employ practice activity, often at the instruction of practice building consultants, to increase practice revenues without establishing the compliance of said activity with applicable laws & rules, including, but not limited to: marketing campaigns to recruit new patients; generation of referrals from attorneys and MDs; convert/retain patients; treatment protocols for all; administer new or re-packaged health care services; provider services rendered by unlicensed staff; use computer-generated noting systems; billing codes to enhance reimbursement; and collection mechanisms to maximize income.
-Explode your practice: Create multidiscipline and/or specialty practices, operating in conjunction with existing chiropractic practices, to avoid limited chiropractic coverage and access more health care dollars - including those payable by federal health care programs.
-We are conveniently located: Operate multiple clinics where scripts and protocols are the norm - instruct clinic doctor and staff on what to do, how to do it, what to bill...
-We provide a good service: Provide the same services at similar intervals for all patients regardless of individual needs. Services involve little actual hands-on treatment by a chiropractor who uses new "state-of-the-art" treatment equipment or has unlicensed staff administer the bulk of patient care.
-We treat the cause not the symptom: Report the treatment of the cause of health care ailments and abnormalities with adjustment of the spine to allow the body's innate intelligence to heal, not masking the symptoms with medication or surgery.
-Benefit design: Provide services not based on established, individual patient needs but on philosophical beliefs - everyone needs chiropractic care, no actual health care complaint required (found if needed for insurance purposes), chiropractic adjustments result in optimal health, same adjustment on all patients (upper cervical, full-spine) and modalities help the adjustment last.
-Wallet Biopsy: Identify available insurance or a willingness to commit to payments on potential patients, even those who are asymptomatic - if an existing revenue stream is found potential patients are told they have medical conditions requiring chiropractic treatment.
-Do you believe: Saying and doing almost anything to generate income from those who indicate they "believe" in chiropractic - purporting to treat acne, allergies, anxiety, bed wetting, cancer, colic, depression...
-You could be hurt and not know it: Provide checkups, under the guise of public service, to identify health conditions that need treatment. Often such checkups, administered on asymptomatic individuals, include use of testing devices not clinically or scientifically recognized for purposes of generating reports that purportedly show medical conditions and a need for treatment outlined in scripted presentations.
-Winner, winner, free chicken dinner: Free or donated services promised in aggressive marketing campaigns - mailers, telemarketing, screenings, dinner talks, etc. - designed to get as many people in the clinic as possible for patient conversion regardless of actual medical need.
-Let's make a deal: Charge insured patients more for services than cash patients receiving similar services. Agreements with insured patients to accept what insurance pays and forego collection of deductibles, co-pays and non-covered services. Varying deals with cash patients regarding what they will pay.
-See you in Court: Use the court system to file lawsuits to challenge payor reimbursement decisions and practices for purposes of eroding resistance to questionable activity - making it the norm and acceptable.
-You are picking on us: Profess to be a victim when held to account for improper practice activity - even when such activity is known by reasonable thinking persons to be inconsistent with the laws & rules governing health care.
Reality: The Chiropractic profession, for the most part, has grown far beyond the limitations espoused by its founder, and is seen today as a bona-fide health care discipline that offers valuable health care services to patients.
Reality: Not all chiropractors engage in fraud. Not all attorneys are shysters. Not all insurers refuse to pay legitimate claims. Not all investigators are out to get chiropractors!
Reality: There is a Chiropractic fraud problem present in every geographic area of the United States, with deviant chiropractors propagating their schemes with impunity and contempt.
Reality: The crime-scene for investigations of health care provider fraud, regardless of the providers' discipline, is the provider's clinical and billing records. And, if you know what you are looking for when evaluating chiropractic records, you can identify the fraud. Investigators view the following as 'red-flags':
- Promised free/discounted services to induce patients to clinic
- Extensive exams, tests and treatment on subjective complaints of injury or on asymptomatic patients
- Use testing devices that are not recognized clinically or scientifically to convince patients they have a condition and need treatment
- Scripts & protocols - same services on similar schedule, even when better
- Services for conditions not found in presenting complaints
- Services based on available insurance or for legal reasons - not actual need
- Provider services administered to patients by non-providers
- Patients direct treatment or treat themselves
- Excessive amounts billed for services
- Goal is to bill certain amounts per visit
- Billing codes reported based on what results in the best reimbursement, not on actual conditions or what was done
- 'Quick-codes' automatically bill for all services insurance covers, regardless of need or if actually provided
- Conditions reported only when required to get paid (Subluxations - Medicare)
- Clinical notes appear same on all patients, prepared to support payment - not health care rendered,
- Clinical notes prepared only when requested by payers - more extensive for liability carriers
Reality: Large numbers of chiropractors see what others see and try to fight for change and accountability, often fighting from an island and dodging bullets of attack from their peers and payors.
Reality: Many otherwise honest and ethical chiropractors succumb to the temptation of fraudulent activity as they see deviant chiropractors getting rich off insurance payments without ill-effects (e.g., consumers turning away, claims denied, government audits, and fraud investigations).
Reality: The Chiropractic fraud problem must be addressed by Chiropractic educators, Chiropractic leaders, consumers, legislators, insurers, regulators and law enforcers if effective measures are to be taken - especially those problems that are already well-known and visible.
Reality: Observe this inexorable recipe that could result in an unimaginable disaster for the Chiropractic profession:
- More access to health care dollars by chiropractors
- Neither substantial- nor quantitative-steps to address widely-known fraud problems
- Failure to take steps to prevent bad-actors from ruining reimbursement advancements for those health care professionals who follow the laws & rules while delivering quality care to patients, is a recipe for disaster that could result in the fraud reaching unimaginable levels.
According to James Edwards, D.C., past Chairman of the American Chiropractic Association, ("News Flash: Obama Victory Could Result in Full-Scope Chiropractic," Dynamic Chiropractic, 1/15/09), the election of President Obama, as well as the fact that Democrats control both houses of Congress, most of whom are pushing for "universal health care," the Chiropractic profession has its best chance to achieve the long-desired goal of a full-scope of practice on a national level (with full-reimbursement access).
Further, Dr. Edwards reports that should a full-scope of practice become a reality, the Chiropractic profession should thank ACA leadership for their courage to file a lawsuit against a national health insurer, an insurer that administered federal health care programs, as well as the countless contributors to the ACA's Legal Action fund who made the lawsuit possible.
Could greater governmental-control over our individual-choices and freedoms, combined with Universal health care, provide any long-lasting positive results? The last time the Democrats had such leverage we got the Health Insurance Portability and Accountability Act.
Could giving chiropractors full-physician status, as well as full-access to reimbursement for services they perform, be an answer to the chiropractic fraud problem?
Could treating chiropractors as other physicians are treated result in a significant drop in the nonsense in which some chiropractors engage? Would treating chiropractors as other physicians preclude having those chiropractors engage in practice-activity that is either objectionable or fraudulent? What impact, if any, did such treatment have on the Osteopathic profession?
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