What are you paid for in a chiropractic practice? When that question is asked around the country, answers range from "adjustments to manipulation." from "exercise therapy to adjunctive therapy." and from "my expertise to my opinion." In every case, those answers are wrong. You only receive payment for what and how you document. In addition, your license is protected by what and how you document since that is proof that you have followed the standards of your license as deemed by your state licensure board. During your professional training, you were taught a very detailed set of skills to provide documentation on your patients. You had classes in neurology, orthopedics. palpation, and specific chiropractic evaluations. You then were taught how to document each clinical finding, whether positive or negative. You received rigorous instniction in cranial nerves and system analysis, ranging from simple vitals to the examination of lungs, heart, and abdomen and beyond. You were tested, tested, and tested again in school and in clinical settings, at the national level, and finally, at each state level. It is fair to say that by the time you graduated with your doctorate in chiropractic, you were a competent doctor who was proficient in creating an accurate diagnosis, prognosis, and treatment plan with the ability to document those findings. After graduation, too main seem to dismiss the value and importance of the detailed documentation they learned in school and the necessity to accurately and compliantly document. There arc a myriad of reasons behind the acquired cryptic format of documentation that main have adopted. The range of reasons, as reported to me, are as follows: "It takes too much time." "It is not necessary to know where and when to adjust." "I have never been asked about most of the stuff required in school." "I don"t bill insurance." "I have a small practice and fly under the radar." "No one I know has been audited." "I don"t take Medicare or mandated EHR insurances." According to credible sources within the organization of defense lawyers (yes. insurance company lawyers have an organization), the easiest cases to win arc those against chiropractors who continue to use travel cards. The reason is that travel cards arc historically the most cryptic, documenting the least amount of information, and as a result, nearly impossible to defend if challenged. In addition, after reviewing hundreds of travel cards for doctors from most states. I would concur and report that very few of those doctors who utilize travel cards meet cither their state or federal requirements for appropriate and complete documentation. EMR systems (electronic medical records) arc at the opposite end of the spectrum. These "man els of technology" are a double-edged sword. Although they strive to be extremely thorough in meeting required standards, they arc typically owned and coded by non-doctors who often dont understand how to practice chiropractic. As a result, they arc often too cumbersome, require someone with significant computer skills, take too much time, and sound nothing like a human interacting with the patient. Most doctors fall into the pattern of documenting almost the exact same thing for every patient, and if you read 50 reports, they would all appear to be alike. If ever investigated, this pattern would be just as problematic as the poor documentation found in travel cards. When considering purchasing or working with an EMR system, you must be prepared to make significant "custom-izations" so that it meets your practice needs and reads like a human prepared the report and not a computer. Although EMR systems have made tremendous strides through the years, there is still quite a way to go and I can assure you that in 2016. your system will look nothing like it docs today. As a result, you must be vigilant to ensure what you arc attempting to report is accurately reported. According to Dr. Studin. "Based on my experience, relationships, and most importantly, my credentials. I have been retained as a consultant for fraud, licensurc. and audit proceedings. As a result, and primarily through the power of subpoena as an expert for the defense. I have been exposed to the issues and tactics of the carriers, various governmental agencies. SIU (special investigative units), and aggressive defense lawyers for the carriers. In each scenario. I can state with a great degree of certainty that the level of documentation was the arbiter for if the doctor prevailed or had his or her life "turned upside down" in a losing scenario or even in settlement". Recently, a doctor who was defending both a licensurc issue and retrospective audit on the same case. This doctor practiced in a 100% cash practice that was relatively small and for mam years practiced well "below the radar." This doctor's business policy was that he would only take cash and give the patient a receipt to bill his or her insurance company, if the patient chose to do so. One patient sent the receipt to the carrier, as usual, who had previously paid the patient based upon the patient's previous requests for reimbursement. This time, however, the carrier requested backup documentation from the doctor and upon receipt of the doctors "cash only" cryptic travel card information, both refused reimbursement to the patient and launched a fonnal investigation on the doctor for every claim that each of his previous patients had submitted in an attempt for retrospective repayment. Additionally, the patient demanded 100% repayment as a result, and when the doctor refused, the patient reported the doctor to the licensurc board for fraud. This is one of those cases that no one will ever hear about. When you sit in your office and say. "No one I know has been audited and I am Hying under the radar." it is because no doctor will be a "braggart" about the above scenario. As a side note, it took a $500 per hour healthcare lawyer, two years of sleepless nights, and more than $ 100.000 in settlement to make all of the retrospective issues disappear and avoid criminal charges. To this date, licensure misinduct charges and fines are still "hanging over this doctor's head". In another scenario, a seven-ycar practitioner in a retrospective audit from a personal injury carrier ended up with federal RICO charges because the carrier claimed the doctor used a paper instrument and the US mail to allegedly defraud a financial institution, the insurance carrier. This doctor used one of the better EMR systems, but he was not diligent about noting changes from visit to visit. This created a pattern and the carrier was able to go back seven years in a suit against the doctor for $550,000. This is a typical carrier tactic. When they find one issue, they claim every previous claim was fraudulent and add that into the case. Essentially, it is the theory of "throw enough against the wall and sec what sticks." When you create a suit under federal RICO, it carries both treble damages and requires a federal defense lawyer who is significantly more expensive. After doing a forensic analysis on only 10% of the cases, it was recommended to the attorney that the doctor settle out of court because there was no way to make an argument that could explain the lack of changes in his patients progress because almost every patient had the same findings. This doctor settled for $550,000 plus a $200,000 legal defense. In cither or both scenarios, if the doctors had followed what they were taught in school regarding documentation, then both would have prevailed in their respective cases. To further underscore the issue, neither would have been in the position to be audited or sued if they would have followed the academic standard they were taught in school, which is also the standard of most states. Most initial evaluations take approximately 30 minutes, including the documentation, even with a very thorough paper SOAP note, which takes only between 60 to 90 seconds to complete in a compliant scenario, if you engineer the document properly. Documentation is about many things. It enables you to be paid, it allows you to keep your money in a retrospective audit, and it protects your license. However, most miss the most critical reason for having an appropriate level of documentation: to help and protect your patients. It gives you a chronology of their histories and their clinical findings. Precise patient documentation ensures that the clinician presents an orderly chronology of diagnostic findings, therapeutic interventions, and patient outcomes. Your documentation is also a way of communicating with other physicians who arc cotrcating the patient. It enables other physicians to easily understand what has occurred while the patient was under your care. Other physicians may be concurrently treating the patient or trying to unravel a future diagnostic dilemma. Most chiropractic institutions today begin instruction early about the necessity of proper documentation procedures. These skills are honed during the didactic portion of the students" careers and then expounded upon during the clinical portion of the chiropractic program. As practitioners, any of the previous seven (self-centered) reasons for not maintaining a professional and required standard of care for your documentation arc unacceptable. Personally, the authors like being paid and sleeping at night without the specter of litigation, and most importantly, realize that documentation is at the core of being the best of the best tlirough clinical excellence. Dr. Mark Studin is an adjunct assistant professor in clinical sciences at the University of Bridgeport College of Chiropractic and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MR1 spine interpretation and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www. LawyersPIProgram.com) and teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally (www.TeachDoctors.com). He can be reached at Dr.\(ark(8} TeachDoctors.com or at 631-786-4253. Dr. Al Cantito is an Assistant Professor at the University of Bridgeport, College of Chiropractic. He has been the Student Clinic Director for the past seven years. He also works at Mic/cllebury Chiropractic and U'ellness Center in Middlebury. CT. practicing chiropractic and acupuncture. He can be reached for questions or comments at acanlito(abridgeport.edu
