Blog, Chirosecure Live Event July 12, 2022

Multi-disciplinary Practice Risk Areas

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

I always like to tell folks about the multidisciplinary model that you may or may not hear from a consultant. That’s trying to pitch you on that model.

Is that it is one of the more risky things that you can do as a chiropractor. And I’m not saying that you should do it. But I always docs going in eyes wide open so that they understand what they’re getting into, what their. Demands and obligations are going to be transitioning from treating doctor to business manager so that you can, in the context of informed consent, if you will, that you know what you’re getting into so that you’re not into it by six or eight months.

And then you find out the truth and then realize you maybe would have made a different decision. So the first thing that you have to understand about modern disciplinary practice is that it is not perceived well among the folks in the government SIU folks for commercial payers especially where the the owner or manager of the practice is a doctor of chiropractic.

In the government’s experience chiropractically owned, managed, and or controlled. And we’ll talk about issues of sham ownership and things of that nature, that it, how they’ve come after these folks. But They, their default is that it’s a criminal enterprise. And in which case, knowing that going in, there’s some things that you need to be very cautious of in terms of what you do and how you run your practice to make sure that you don’t trigger anything that would substantiate that the false perception, if you were ever to get looked at now, depending on the state.

Under what are called corporate practice of medicine or the corporate practice of medicine doctrine a chiropractor may or may not own some or all of a medical practice. So depending on state law You can in some states own the entire practice and hire medical professionals and all of that in states where you cannot the model usually involves granting ownership of the medical corporation to the medical doctor without any financial investment at least not upfront sometimes not even on the back end.

And then there is a management committee. That is owned by the chiropractor that effectively manages the medical practice and provides unlicensed staff, billing services space, equipment, and so forth. And you have to be very cautious in those scenarios because the way that the government takes those down is usually with what they call a money line.

Effectively, what happens is that the management agreement is not a fair market value arm’s length transaction, meaning that the management company’s fee, if you will for their services is whatever the medical corporation makes. In reality, no medical corporation would contract arms length with a management corporation under those terms.

And that’s why the government, blows apart any of those agreements. So if you are going to have a management corporation, To manage the medical corporation. You got to make sure that you it’s a deal that you would do with a third party. So if you’re going to provide billing services, you have a billing services agreement.

If you’re going to provide staff, you’re going to provide part of the agreement is going to be, who they are, how much they’re going to pay for. And usually these are fixed amounts. You’re going to rent equipment. You’re going to rent space. It’s going to be fair market value.

And if you’re not sure what that is, and you get a fair market value consultant, to evaluate what you’re providing and what you should charge for it. So that it does not appear to be a sham arrangement. Once you get over that hurdle. The problem that most docs it will. How am I going to make money?

You’re going to make money as the management company, but that’s all you’re going to get to make well, but what about all this other stuff? And when you don’t own the practice, then you can’t get a K one. So you don’t get to share in the. Of the medical corporation. And that usually at that point, it’s if I can’t make money off of them, then I, or at least all the money, then I don’t, why would I take the risk?

And that’s a business decision that you have to make. The other issue that the government is concerned about is what they believe is a sham ownership by the medical doctors so that the medical corporation is in itself a sham, even though the medical doctor has all the stock or the requisite amount of stock, 51%, 90%, whatever the state law requires.

When they’re gifted that stock. And as part of their compensation, they’re not having to pay for that stock, meaning they don’t get fully vested into their stock, such that when they leave, normally what happens, they just transfer the stock to some, the next doctor that comes along. That the government looks at is sham ownership.

And if they can undercut the validity of your medical corporation, then they can undercut the validity of your reimbursements and argue that they were fraudulent. The gain. The other issue is that is an issue of control. When so whatever medical care is being provided. As a chiropractor because you’re not licensed to provide medical care.

You can’t exercise any control whatsoever over that medical care. And unfortunately, in many cases that occurs because the protocols of care, what type of medical care the practice is going to provide, even though the chiropractor doesn’t own the medical corporation, it’s a chiropractor making those decisions.

And when the government comes knocking and they threatened your MD with exclusion from Medicare, they’re going to roll over on you. And that unfortunately happens. And they prosecute the chiropractor because that’s who they really want is the decision-maker. If you read the Agee grandson memo in their fraud prosecutions, they’re going after the actual decision-maker.

And if that’s you as a chiropractor That’s not good for you. The other issue is that The in addition to control over the care that creates another potential fraud issue in so far as the government will argue, and they have argued this successfully, that in essence, there’s a provider, MIS identification fraud is the chiropractor.

That’s really making the decisions about what type of care, how often, and what. And we’ll talk about some scenarios here in a minute where that’s going to make a little more sense. Had the service has been built under the chiropractor, who was the actual decision-maker. They wouldn’t have been compensable because you lied and said that the medical doctor was making all the decisions.

The that’s the basis of. Or a basis of a fraud prosecution in these multi-disciplinary cases. Now, no doubt. You will have agreements where the medical doctor has to exercise independent medical judgment, blah, blah, blah, blah, blah. But they just won’t believe it because one they’re going to have the medical doctor in their pocket.

I just did what Dr. Told me to do. And maybe they don’t have training and the type of medical care that they’re providing. So they, just adopted protocols and anyway it gets to be a sticky mess and because the government has successfully prosecuted cases under those circumstances, they won’t hesitate to bring.

And usually it comes in a civil context, but in some cases the criminal AUC gets involved and they’ll land an indictment depending on the totality of the the conduct that they’re looking at. Okay. There’s also beyond chiropractic control, we often see incident to problems. And just to explain briefly, the incident to rule is one of the three rules that allow you to lie about who did the service.

So imagine just in your chiropractic context you have a chiropractic assistant that you’re legally permitted to delegate. The performance of applying the stem, turning the machine on pursuant to your instructions and orders. You’re doing the exam of the patient, the diagnosis, the plan of care. You determine the patient needs them.

Mike, the monkey boy just goes in and puts them on by put the pads where you tell me to put the pads. I turn the knobs where you told me to turn the knobs and I set the timer for how long you told me, set the timer for. You’re the decision maker and therefore you are allowed to bill that service as if you’ve personally performed it.

That’s what the incident to rule anything that I would be doing as your chiropractic assistant would be incidental, although integral to your professional service. The same concept applies in medicine, of course. And it’s used more broadly there either between medical doctors and mid-levels.

’cause mid-levels are cheaper. Your medical doctor, owner may or may not be on site all the time. You have a mid-level in there, and sometimes I see practices, erroneously billing, everything under the medical. Rather than the mid-level and the doctor wasn’t there, the doctor didn’t do the initial exam.

Didn’t develop the plan of care and having the doctor, review the notes and pencil whip off on them indicating that the mid-level, whether it’s a PA or an NP is really smart and knows what they’re doing. Doesn’t change any. So substantial liability can arise there as well. And if your mid-level is not credentialed then you’ve got a bigger problem because all the money’s going back.

So in those scenarios, if you’re actually utilizing a mid-level provider licensed provider to actually do stuff, then and do the medical care. Then you’ve got to bill under the mid-level and take the 15% reduction because under Medicare and even in some commercial plans, they get reduced compensation and that’s because they don’t cost as much as a fully licensed physician beyond that problem.

Sometimes the mid-level isn’t actually doing everything like they’re supposed to, they’re delegating to unlicensed staff. You need to watch out because in many states mid-levels, don’t have. The authority to delegate services down to anyone. Especially PAs in some states I’m seeing NPS the nursing boards are understanding the need for this.

And they’re writing it into their regs, but it’s not really caught on across the nation. Before you bill for something under your mid-level, that your mid-level didn’t personally and completely do, make sure that they have the authority to delegate those tasks such that your billing would be accurate.

Now beyond those general problems there’s a couple of different management protocols that, that these multidisciplinary management companies sometimes. Put out to their clients that caused some problems. The most common one is you’re incorporating multidisciplinary practice because you want to do pain management injections.

Pay pretty well, it’s a pretty lucrative area of practice, but they come with an enormous number of restrictions regarding medical necessity. So whether it’s trigger points, tendencies, major joints, you need to be very careful that you’re understanding what those limitations are and you don’t play games to get around the limitations.

And these are the games that I’m talking about. Usually you were permitted, let’s say for trigger point injections. Or let’s take a major joint injection to do it one injection every three months. So you can do a maximum of four year. So we inject the knee this month. We inject the next. The next month, then we do the low back the next month.

Then we go back to the knee and you play this round Robin game of changing areas so that you can justify doing a major joint injection every month, but they’re not done there. Then they’re going to find tendencies and trigger points. And they’re going to give you these documentation approaches that you find the right diagnosis and you’re filling in all the blanks, but the utilization pattern is what’s going to get your burn because your utilization is going to be extremely.

In terms of the amount of injections that you’re doing for your patients across the board. I call it the pin cushion protocol, where you treat patients like a pin cushion and you’re just stabbing the crap out of them. So be very cautious about protocols like that. Yes. The ROI on it is huge, but so is the risk.

Be very careful there. The other problem is that even though it’s not per se. Illegal or improper necessarily. As a doctor chiropractic, you want to do chiropractic care and the medical doctors going to do their medical care and a patient comes in, they’re going to do a medical exam.

You can do a chiropractic exam and you’re going to do your chiropractic thing and they’re going to be doing their medical thing. And you’re going to, co-manage the patient that is death on a. Two reasons. One, the two types of care are oxymoronic opposed to each other. For conservative care to be medically necessary.

You have to have an expectation that it’s going to work. And if that’s true, then they don’t need injections. And injections. If you look at most medical policies, that pain management is only medically necessary. If conservative care has been attempted and failed. So right out of the bat, with co-management, you’re working these two types of care at odds with each other.

Such that both are likely to be excluded in post-payment review or denied is medically unnecessary at a minimum. The second problem is that as a chiropractor, you are now engaged in a treatment relationship with a patient at the very same time they’re in they’re receiving medical care. And as an owner or manager of the practice, the government is never going to believe that you were not influencing medical.

So in, in if you’re trying to avoid tripping that I’m a criminal enterprise flag with the government, in terms of their perception, you never co-manage because you take your shot at the patient. Chiropractically do your car conservative care. If it works great, the patient goes on their way, or maybe transitioned with cash that doesn’t work and they need medical care.

You send them to the medical folks and you never talk to that patient ever. You don’t, it’s like you send them down the road and it’s the only way to stay compliant so that you don’t have patients saying, who’s your doctor and they call you out as opposed to the medical folks, what about this medical guy?

I think I saw him once, but I don’t, and I remember this case years ago. And every single patient who’s your doctor? It was the chiropractor. And the reason why, because the chiropractor was doing the report of findings and talking to the patient about their medical care.

Why? Because the chiropractor was better at it and that you can’t do that because it makes it you’re given the government, all the information they need to demonstrate that you’re controlling medical. It’d be better off. If you had a case manager who was unlicensed do that was working on the medical side, then you as a chiropractor, you want to do it.

Why? Because you’re better at it. You want to close these patients. You want to make that money. I get it. Okay. But in, from an evidentiary perspective in, when you’re looking at this retrospectively, when the government’s, threatening to bring an indictment or bring in a fraud case it’s just the worst evidence in the world that you can ask me to do.

Because there’s no way around it. And I’m never going to convince an AOSA that you weren’t controlling the care, especially when the AOC has already leaned on your medical providers and. That you told them what to do. I just did what Dr. Told me to do, and that’s how it turns out. So you need to understand that and set up very harsh firewalls, segregating, conservative care for medical care.

If you got PTs, you got to plan your patient flow. You’re going to do the chiropractic impassive therapies. Then the PTs are going to do the rehab. And then if that doesn’t work, they go to medical and whatever happens to them over there happens to them over there. And it brings up another. To carry this off.

You have to have a comp, you have to have a competent medical team. They have to know what they’re doing. If they’re looking to you for how to practice medicine, you got the wrong folks. They need to exercise independent judgment. They need to be competent, which means they’re going to be expensive. If your medical director is, working with you in 47 other clinics, wrong guy because the government knows.

Find somebody that you know, can not only where it’s required, either supervisor, PAs, or collaborate with your NPS be your medical director and actually do the work. This is not a retirement income where you pay him so much a month just to come in and pencil. Once a week if you’re going to hire a medical director, then hire somebody that can actually direct the medical side of the practice.

And earn that money. I saw a case recently where the medical doctor it was an incident to problem where all the services were built under this medical doctor. She had her own practice and the government’s looking at billing or she’s billing out of multiple places at the same time.

Obviously she can’t be in all these places. And that’s what started the investigation. And the doctor was very happy to take the amount of money she was being paid each month to be the air quote, medical director for all these different practices right up until the point where the government started.

At her. And what does she do? She turns around and files a key Tam case, which is a civil fraud case on behalf of the government to save herself and profit off of whatever money the government got back off of the the multi-disciplinary practice. Set that up carefully, make sure you have competent medical folks and make sure that you allow them to figure out what medical care they’re going to provide.

If you can own part of that practice. Yes. You can make money off of them depending on your percentage of ownership, if you can’t own that practice, the only thing that you can make money off of is. Side of it and make sure it’s fair market value. Some other protocols that are problematic or have been problematic in the past.

There were some recommendations for these neuropathy protocols where they were do lidacain injections nerve injections. To deaden the nerve. And then they were treating the neuropathy with electric stem. The government took the position that you were treating neuropathy with these lidacain injections, which is not covered.

And not only did they take all the money back, but they prosecuted everybody. They found doing it. And I was involved in one of those cases, working with council down in Florida, we put together, an exquisitely detailed white paper and analysis. In of that, it was the stem that was being used to treat the neuropathy.

The injection was only done so that the stem didn’t Drive the patient, set the patient on fire and allow them to apply that stem without it causing the patient’s significant discomfort and the government understood it. And they said, we don’t care. We’ve won this case, either settle, double damages or we’re going to take your.

And given the risk, the expense, you take the settlement, plus they, they willed an exclusion hammer and you get excluded from Medicare. You’re pretty much done. Some other things P stem, NSS, they’re these little ear. As a matter of fact, I have one right here. Your things with these little electrode pads that have these very tiny little needles in them.

They were billing them as implantation of an electrode array. Obviously it’s not a lot of folks got hurt, but in the context of that issue, it exposed other issues in their multidisciplinary practice. It was very lucrative. Right up until the point where the government found out about it.

And then I did a disclosure for a client in California over. Interestingly enough, we started that right before, about three weeks before safeguard started nosing around. And so we avoided the false claims liability associated with that, but it will recoup $589,000. And he was only involved in it for nine months.

So yes, generate a lot of money, also generated a lot of liability. The last one that I see prevalent with multi-disciplinary providers is the, I won’t call it regenerative medicine, even though that’s what folks usually call it because there’s no FDA. To suggest that those products regenerate anything but the human cellular tissue products, those injections, I’m fine with doing experimental investigational stuff.

It’s just all about the disclosures. Don’t get you snuckered into believing that you can bill for any of this stuff. The Medicare you can’t, you will go down in flames. I have two of these cases. They’re are looking to prosecute my guys for fraud and double damages is the opening. Argument for settlement.

And it’s an amount that the dock cannot obviously afford. So be very cautious and long story short. If you’re being pitched with a proposal that involves here’s your return on investment? Senexis is another one that’s causing problems recently and they’re showing EOB ELBs run away.

But Not withstanding all of these problems. I’ve seen them on a disciplinary model work. It can be run compliantly. It requires a lot of work. But just like anything, there, there’s no easy money in medicine, but there is money in medicine. And if you’re willing to understand the rules about how to do more disciplinary practice it can be implemented both effectively compliance.

And also profitably. So that’s all we have time for today. Sorry that went a little bit longer, but it’s a big topic next month. We’re going to do a a cash panel. So be sure to check in for that on August 9th and next week, I’m going to take a guess. And it’s Dr. Sherry is with us and Dr.

Sherry McAllister, and she’s going to have a great topic for you. So until next month you guys have a great rest of your day.