By Stuart E. Hoffman, DC, FICA
There is an ugly specter looming on the horizon for many doctors of chiropractic, a potentially devastating and costly one, and I suspect very few practicing DCs have ever given it any thought. Here is the story: Managed care contracts which you sign usually set far-reaching and demanding extra-legal terms and conditions for participation. They want to limit your diagnostic procedures, especially x-rays, they want to limit the timing and volume of care, and in some instances they even want to prevent you from discussing these limitations with anyone, including your patients. It is no wonder that the entire profession is in an uproar, and rightfully so. The International Chiropractrors Association (ICA) is involved in a deep dialogue with federal agencies about urgently needed new enforcement of rules against predatory trade practices, price fixing and similar anti-competitive behavior that have not as yet been applied in healthcare and the health insurance industry. This kind of federal action is urgently needed and ICA has my full support, and should have yours as well.
So, here is the situation. When the 900 pound gorilla in the room says you cannot take x-rays except in a few limited circumstances, regardless of what your professional judgment and conscience indicates; says you must limit care to a handful of visits, etc. etc., where do you stand in terms of malpractice liability? Right in the center of the liability bull’s-eye! The reality is that in light of all of the demands to limit examination procedures, diagnostic imaging, and the actual provision of care, no managed care organization assumes any malpractice liability of the abbreviated care they demand even if it results in a claim. How is that for irony? But, it gets even worse.
These same entrepreneurial organizations, acting as if they have been endowed with regulatory authority over chiropractic and your actions, and now regularly showing up before regulatory boards with accusations of “overutilization” or worse, all based on their self-created and economically motivated rules. These actions and the claims and assertions they are making are sometimes so far beyond established chiropractic norms and practice parameters that the profession needs to question whether these organizations are, in fact, seeking to usurp the unique authority of the state legislatures in the United States to regulate the professions and the trades.
So, the big question now is how do you protect yourself from a managed care organization that wants you to cut corners, even if it means putting you at odds with your responsibilities under state law, and at the same time, likely to show up in front of your state board accusing you of abuse if you don’t abide by their economic scale of services, quality of care notwithstanding? This is a battle the entire profession needs to fight but for now, here are some things you can do:
Know what the laws are regulations are: Every DC should have a current copy of the laws and regulations that apply to chiropractic on file, and it should be regularly reviewed. If you have questions ask your board. Pay special attention to what you are expected to do regarding the provision of timely and appropriate care. To be forewarned is to be forearmed.
Know what you have agreed to: As painful and as time consuming as it may be, you must read and comprehend every section of any managed care or claims administration organization contract you are thinking about signing. If you do not understand what a section means, get help, both legal help, help from your professional colleagues and your professional organizations.
Get an official opinion and be prepared to act on it: If you are concerned that a passage in a pending contract is legally problematic in terms of your obligations as a chiropractor under the law, write to your state board and ask if the section in question is consistent with what the board holds as acceptable. This is a legitimate and integral part of their mission to protect the public, and they should be glad to address your questions. If their response is a negative one, the next step will be to contact your state’s insurance commissioner with that evidence of the problem and demand their intervention. Your state board should be your willing ally in this process, and in fact, should take the lead.
Contact your malpractice carrier and discuss your concerns: An ounce of prevention here is likely to be worth well more than a pound of cure. Ask questions and provide specific details about your contract concerns. As with your state board, your malpractice carrier has extensive experience and broad based resources that can help you do the right thing for your practice and your patients. Ask what they advise you to do, and how you can minimize your liability exposure. Make sure that your malpractice policy covers board complaints of this type as a number of programs offer board coverage but are limited to complaints for providing or failing to provide professional services. This does not cover insurance company complaints! ChiroSecure offer the most board coverage available with our $50,000 defense for any Board, HIPAA, Billing error or insurance audit issues.
Develop and maintain a vigilant risk management program: Proactively develop a risk management plan that focuses on issues and procedures that might be impacted by limitations in a managed care contract. Such steps as clear notations in the patient record that a procedure or the duration of care was prohibited by the plan are a good place to start. Also, be clear with patients about where the limitation is coming from. All of these items should be in writing with your patients signing off so they do not come back in the future claiming that you should have told them.
Be prepared to say no: In the final analysis, there are conditions and terms that you should not be expected to agree to, if such terms and conditions put you and your patients at risk. No one is forcing you to sign any contract, even understanding the economic pressure we all feel in certain circumstances. You can say no.
These are not easy decisions, and as we all know, these are not easy times for our profession. Still, patients need and want what you do. What you do has value and you have every right to defend your self, and a solemn obligation to abide by the laws and rules governing chiropractic in your jurisdiction. In the end, you are the responsible party.
ChiroSecure is also there to work with you in tough situations like these. As a doctors of chiropractic myself with years in the trenches, you will not have to spend a lot of time covering the basics with us. We are here to protect you.