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Dynamic Chiropractic – September 14, 2005, Vol. 23, Issue 19

We Get Letters & E-Mail

"There Is Absolutely No Excuse for Poor Documentation"

Dear Editor:

I read with interest your article, "Is Failure to Document Giving Chiropractic a Black Eye?" in the July 30 issue.

While I disagree with many of the findings of the OIG report, I find the responses of the American Chiropractic Association (ACA) laughable. The official response of the ACA stated: "It is the opinion of the [ACA] that the findings in the report issued by the Department of Health and Human Services, Office of the Inspector General reflect a universal problem in physician documentation and do not represent a concerted effort by doctors of chiropractic to over bill the government for nonreimbursable Medicare services. ... In far too many instances, chiropractic providers are simply failing to adequately document the medically necessary care provided."

In other words, chiropractors aren't dishonest. They are just lazy! They expect to be compensated for services that they fail to document as medically necessary. This flies in the face of reasoning. The OIG, being a government agency, dealt with the issue in a way that most bureaucratic agencies do. It suggested imposing a cap! And chiropractors will continue to complain about how unfairly they are being treated. Yet they will never look at their own shortcomings as the cause of the unfair treatment.

As we move into the 21st century, there is absolutely no excuse for poor documentation. The days of checklist travel cards or office notes consisting of the notation "better" or "same" are long gone. Third parties reviewing chiropractic claims tend to dismiss information that they cannot decipher, such as checklists and nonstandard abbreviations. Computerization should make record-keeping a snap. Yet most doctors are still using archaic systems of note-taking.

In an attempt to upgrade their documentation, many chiropractors have made the transition to computer-generated SOAP notes. While it has helped to improve documentation, there are still several shortcomings. The notes often appear to be redundant, even with randomization of text. If the doctor takes the time to customize the note to the patient, there is no saving of time; it may actually take longer than writing it by hand. It creates volumes of paperwork.

Clearly, the gold standard for documentation is dictation. It allows the doctor to state, in his own words and not the computers, exactly what is transpiring with the patient. It allows the doctor to "tell the story" of patient care and gives the reader of the information (i.e., third-party payor, attorney, etc.) a complete clinical picture.

I have been in practice 25 years. During that time, I have looked at or tried most of the systems available to chiropractic. None of them was adequate for my needs. I needed a better system; one that I could use in a busy practice.

Finally, about one year ago, I made the transition. I have gone to a paperless office, using a transcription service for all of my dictation. I carry all my necessary clinical records for the day in a pocket PC. I dictate on the spot, with the patient in the room. This helps with patient compliance for follow-up care. I can send information to another DC immediately by fax or e-mail. I simply e-mail my dictation at the end of the day to the transcription office (which is HIPAA compliant). The following morning, when I come to work, my transcription is back. It's that simple. My staff no longer has to waste time (which costs me money) pulling patient files every day. And most importantly, it allows me to get paid for the services that I perform.

The cost to set up transcription is minimal ($25). There is no expensive equipment to buy; no $5,000 investment to get started on a system that you end up hating in six months, but can't get rid of because you have to justify the cost. I can now spend more time treating my patients and involve them in their health care. It has given me my life back.

But, most importantly, it allows me to adequately document the medically necessary care that I provide to my patients. Fewer problems with third-party payors translates into more time that my staff can spend on patient care.

Gary M. Estadt, DC, DACRB
Mentor, Ohio

Aren't We All Just Chiropractors?

Dear Editor:

I have been doing the business of chiropractic for the past 27 years now, and I must be like the ostrich with my brains in the sand. However, after reading letters and articles in chiropractic journals, it blows my mind trying to figure out what all that mumbo-jumbo means after a signature of a fellow DC.

Perhaps you can shed some light on this subject and explain what all this letter crap means. I know what the real education letters stand for; it's all those other puffed-up things, like for example, DACBSP, FICC, CSCS, DABCI, DABCN, CCN, and others!

The question that comes to mind is this: Do all those letters after a name make that person important? Are they not just plain old chiropractors like the rest of us? Perhaps not; maybe they are special ... so they may think.

Hmmm, just some food for thought. I am limited in my real degrees, so I will just sign off with my plain old DC degree, and AA, AAA, AARP, VFW, SAR, SGT82AA, AML, DSCF, USIS, AC. Well, you get the drift. Who really gives a rats...

Thomas G. Shaw Jr., DC
Huntington Beach, California

A Word About Student Loan Debt - From a Chiropractic Student

Dear Editor:

I received my undergraduate education at the University of Central Arkansas and am currently in the first semester of working on my chiropractic doctorate at the Logan College of Chiropractic. I think you should open a discussion forum about how chiropractic students are supposed to repay their student loans after graduation.

I already have two degrees and am about $30,000 in debt. I would like to open my own practice when I get out, but the amount that I will owe by then is going to be $200,000. I don't think anyone in their right mind would loan me money to open a practice. Also, when I graduate, I'm going to have to pay back about $1,000 dollars a month in loan payments, so I don't know how I am supposed to make a living paying this much a month. If anyone has advice or would share personal experience about this issue and ideas on how to do it, I would really appreciate it.

Ryan Poynor (chiropractic student)
St. Louis, Missouri

"Let's Get Real and Do Away With the Smoke and Mirrors"

Dear Editor:

There is an emerging threat that has only been recognized for its seriousness recently, and it appears that prominent people in our profession are beginning to realize the true gravity of our situation. The articles that have been published in the big media publications (DC, Chiropractic Economics, etc.) regarding the OIG findings related to chiropractic and Medicare billing are only the beginning. It is time for the ACA, ICA, WCA and all chiropractic organizations to lock arms and work together. If we don't, there will be no need for these organizations because there will be no chiropractors who will have a license.

If you think for a moment that this is alarmist thinking, you're in for a shock and soon! These ole' boys want you and want you bad! I attended a chiropractic state association meeting and the Medicare auditors were there, speaking. Let's start with Medicare reimbursement. I get reimbursed just shy of $25 per visit when it's all said and done. It costs me a little over $21 to produce that adjustment visit. Now, everyone wants me to do all this complex paperwork to substantiate, validate, vindicate and allocate these visits! God knows I don't want to give chiropractic a "black eye" reputation. The fact is that most chiros have been taking care of Medicare beneficiaries for decades successfully without any of this paperwork. More paperwork will not improve the outcomes for these patients.

So, why is all this stuff going on? I'll cut to the chase. The bottom line is that the insurance industry has effectively gotten the government to do their work for them to achieve cost containment. More paperwork slows down claim processing and decreases the amount of claims that have to be paid (cost savings #1). That worked for a while, and then doctors got more efficient and developed methods to provide the paperwork faster, and so they came up with cost savings (method #2). Since chiros got laws to get their claims paid or denied within 30 days, the chiros can get on the phone and make demands to the insurance companies and demand their money, as well as interest on their money. So, the insurance companies had to come up with a way to regain control. So they enlisted the help of the government through the OIG, so this additional help would be paid for by the taxpayers (remember them?) who are being denied the care they have paid for (Medicare beneficiaries).

So, what's going to happen?! Some day, chiros will wake up and realize: (1) There's not enough profit in seeing Medicare Beneficiaries especially considering the horrendous risks associated with billing Medicare carriers if you should make any errors, even "clerical errors" (which by the way, is "no defense," according to Medicare auditors); and (2) Considering the mountainous paperwork and in-office auditing procedures that must now be done, it is not worth seeing Medicare beneficiaries, especially when you can get other case types that are far more profitable and much less risky! (Let's not forget the added costs associated with the audit you pay for yourself through a practice management consultant or attorney, to make sure you are doing everything correctly!)

The best solution: OK! Let's get real and do away with the smoke and mirrors. Someone needs to stand up and say "Hey! Enough is enough"! All this additional documentation does not add to the quality of care for these people. I don't care what the other professions think about chiropractors' paperwork. I am not opposed to improving my paperwork (because I am doing this as we speak), but this is getting out of hand. Who's behind it? The insurance industry! The only way to stop this is to go to Capitol Hill and tell the truth! Medicare beneficiaries are going to get denied the care they want and the care they paid for because the insurance industry is maliciously getting the OIG (funded by taxpayers/Medicare beneficiaries) to come down on chiropractors by threatening their lives (loss of money through fines, repayments, and fraud convictions leading to the loss of their licenses due to the state boards after a fraud conviction). This is all veiled under the guise of trying to stop fraud to cut the government's budget, etc. If you're a chiropractor, you know better. Chiros mostly are just trying to do a good job for their patients. The insurance industry has turned this into a political issue to manipulate the situation to get what they want. Only our politicians can make the OIG back off. We are out of time. Years ago, you could go to someone like Strom Thurman and get this handled in one phone call. It is not nice to do this to Medicare beneficiaries, period (especially if you want to get re-elected)! We must stop the madness!

Who's going to be the one to blow the lid off this issue and expose it for what it really is? Which politician is going to be the one to expose the truth? Rising medical costs aren't coming from fraudulent chiros - try looking at the people with the big buildings ... the hospitals. There you will find the problem. Side note: I am still getting reimbursed about the same by Medicare as 15 years ago. How is that causing rising medical costs at three times inflation?

Jeffry T. Stallings
Owensboro, Kentucky

Let Chiropractors Take the Musculoskeletal Exam

Dear Editor:

I found the article on MDs failing the musculoskeletal education exam very interesting ["Musculoskeletal Education: MDs Still Fail the Test," Sept. 1 issue:], but I do have one concern: I didn't see any figures on how DCs faired when taking this exam. It is clear that the other doctors did poorly on the exam, but how do you draw the conclusion, "Patients would be best served by receiving care from a health care provider with more musculoskeletal training - a doctor of chiropractic," when there are no figures on how DCs did on the exam? You can only make an assumption that DCs would be better without that very important data.

Without knowing how DCs would do on this exam, all we can conclude is that this is a very difficult exam. However, if this exam were ever given to DCs to show a true comparison, it would be a powerful statement of the strength of our profession.

Nathan Eldredge
WSCC Student

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