What's the Catch?

Use due diligence when choosing equipment, practice management partners and educational programs.

By Rebecca Jones

Consider the four scenarios below, and see how many red flags you can spot:

1. A practice management company does more than help you set up an efficient front desk; it also advises you on how to clinically manage your patients, and specifically encourages you to engage in high-pressure marketing strategies to dramatically increase your patient load.
2. A new device you’re considering buying doesn’t actually have its own Current Procedural Terminology® (CPT) code for insurance billing purposes, but the vendor provides you with multiple CPT codes you could use instead, assuring you that it’s perfectly all right.
3. “And after the seminar ends, you’ll have the opportunity to purchase Dr. Smith’s line of books and CDs, and to sign up for additional classes or become a regular client…”
4. “This super-discounted lease price is good for today only, so don’t wait and don’t miss out on this incredible opportunity!”

Any of these smell fishy to you? In fact, they all do. But if you failed to spot all four red flags, you’re not alone. Unfortunately, in the annals of gullibility, doctors of chiropractic have long been counted on to be easy marks for unscrupulous salesmen.

“Once you become a chiropractor, it’s like having a target on your chest,” says Ed Feinberg, DC, DACBSP, professor at Palmer College of Chiropractic West in San Jose. “People always want to sell you something.”

Not all the things they want to sell are good—for your patients, for your practice or for your bottom line. Doctors who invest in devices or services of questionable value are victims just as much as the patients who ultimately receive below-standard care, says Stephen M. Perle, DC, MS, professor of clinical sciences at the University of Bridgeport College of Chiropractic. “But the doctors have an ethical responsibility to ensure that their treatments adhere to the highest standards of excellence and should attend to their patients in accordance with established best practices,” he says, quoting the ACA Code of Ethics. “Patients might be credulous, but we have an ethical duty to be more skeptical.”

Being skeptical means doing due diligence before investing in any new diagnostic or treatment equipment; before choosing a practice management company, business coach or another professional adviser; or before enrolling in educational seminars on new techniques or treatments.

What does due diligence look like? Here are some suggestions from colleagues who specialize in ethics, in practice management and in insurance issues—three areas in which due diligence is especially critical.

Purchasing New Equipment
Daniel Staight, DC, sometimes shakes his head in amazement at the claims some of his colleagues fall for. “It remains a mystery to me,” says Dr. Staight, who practices in Casper, Wyo., and chairs the ACA’s subcommittee for ethical practice, which advises ACA members on the subject of “offers too good to be true.”

“One of the devices we’re looking at now is the ionic footbath,” he says. “You put your feet in this device, electrical current runs through it, and the claim is that it’s drawing toxins out of your body through your feet. There really is no biological plausibility as to why this would work, no credible literature to support that claim, yet it’s being sold, even though there simply is no evidence that it’s doing what they say.”

Dr. Staight says the key to spotting overblown claims is to be well-read. The ACA Web site addresses a number of device claims-versus-best practices standards. In particular, check out the resources under the heading “Insurance” and read the ones that address best practices and ethical practice. You’ll also find a whole section on “mobile diagnostic services,” an area that is especially ripe for abuse, he says.

“We try to keep tabs on the trends in chiropractic and to do some pre-emptive strikes in informing our members about the things they need to watch out for,” Dr. Staight says.

But even doctors who don’t regularly visit the ACA Web site have other easily available resources online. “You might start with Google,” says Dr. Perle. “If you’re looking at promotional material from a company, the harder they push, the more circumspect you should be. The bigger their claims, the more likely the claims are baloney.”

Dr. Perle screens medical devices employing the same strategy he uses for any online shopping: He looks for the customer reviews, and then ignores the positive ones. “I only read negative reviews,” he says. “The positive reviews could have been written by someone in the company. If you read the negative reviews, it may not give you the reality, but it gives you the cautions to look for.” If he can’t find any evidence that the device is worthless, then he feels it might be worth investigating further.  

Certainly doctors should ask vendors for documentation of any claims they make, but Dr. Perle advises being wary of relying solely on what they supply. “They may say, ‘Here are five references that say my device is God’s gift to humanity.’ But you have to read the paper itself, not the synopsis. They’ll give you stuff that tells you how reliable something is, but if you actually read the paper, you’ll find the methodology used in the research is for a different method than is used by the person selling you the equipment. So read the literature.”

Be wary, too, of limited documentation. If the literature refers to 30 studies on a topic, and the vendor provides you with only five, it’s a good bet the unoffered studies dispute the findings of the ones you’re given. “When someone cherry-picks, that’s always telling,” Dr. Perle says.

For doctors who don’t feel competent to do the needed research themselves, ask others. “Ask a colleague,” advises H. William Wolfson, DC, a recently retired chiropractor in Commack, N.Y. and chairman of ACA’s practice management committee. “Ask them, ‘What did you buy? Does it do what they say?’” Dr. Feinberg tells his students to develop a network of individuals they consider trustworthy.

State and local professional organizations and regulatory boards are another good source of information, particularly for clarifying what procedures are lawful for DCs to do in a given state. “What I’m allowed to do in New York may not be what I can do in Minnesota,” Dr. Wolfson says.

When considering leasing a piece of equipment, make sure you have time to study the lease before you sign. It’s a good idea to have an attorney look at it, as well.

“If a company refuses to give you the lease until you sign, you don’t want to do business with that company,” Dr. Wolfson says. “And having a contract attorney look at the lease may be the best $400 you ever spend. Have that attorney go over it and see all the pitfalls, because a company will write a contract with the best terms for them.”

Richard Vincent, DC, a longtime and well-regarded practice management consultant based in Massachusetts, advises making no major purchases without first consulting with your accountant, who can help you make sound business decisions. “Never purchase something from an emotional perspective,” Dr. Vincent says. “Vendors will use language designed to tempt you. But you should have an annual budget for equipment and training expenses, and everything requires some break-even-point analysis: If I purchase this product, how many times must I use it in order to get the return on my investment where I break even?’ That becomes very important.”

Dr. Vincent goes a step further and advises DCs to avoid investing in any equipment whose sole purpose is to make them more money. “If an ad is designed purely around a device’s economic benefits, that’s a flashing red light,” he says. “If the ad focuses on providing a higher quality of clinical delivery or patient service, then that’s an entirely different story.”

Choosing a Practice Management Company
Due diligence in choosing a practice management company, a business coach or any other professional partner involves many of the same strategies as choosing a new piece of equipment: Ask colleagues for their suggestions, and be wary of companies or individuals that make promises that seem too good to be true.

“I was once a client of a practice management company, and almost everything they told me to do was either illegal or immoral,” says Dr. Perle. “They’ll tell you to X-ray everybody. Then you’ve got to get everybody to sign up for 12 visits, or do unlimited care for a fixed fee, which in a lot of states is illegal. But they do an outstanding job of making it sound like they’re just teaching you how to be a good doctor and, by virtue of that, making good money.”

Dr. Vincent is adamant that practice management companies should never offer clinical advice. “If a company tells you how to manage your patients, find a different one,” he says. “If the focus of the management company is strictly on getting new patients, that’s another red flag.”

Dr. Vincent says practice management companies’ true benefit lies in assisting chiropractors in setting up better office routines, in improving interpersonal skills and in fostering better staff management, better business planning and more community immersion.

As with leases, contracts with practice management companies should be vetted by an attorney. “Some of these consultants charge $10,000 or $20,000 a year, and there’s language in the contract that may not allow an individual to escape the contract. I would certainly want my attorney to say, ‘Whoa! This is not something you want to sign,’” says Dr. Vincent.

Be aware that unscrupulous practice management consultants may advise a naïve doctor to engage in fraudulent practices—such as failing to charge co-pays—but that’s no defense in court. “It’s your responsibility to make sure that what you’re doing is legal in your state,” Dr. Wolfson says. “So ultimately, a doctor brought up on ethics charges can’t say, ‘This is what I was taught by this company.’ Whatever you do in your office, you are responsible for. That’s the key. You have to be diligent.”

Enrolling in Educational Seminars
Dr. Perle’s first rule for selecting an education seminar is simple: Will the speaker make money on you after you walk out the door?

“Is the purpose of the seminar to educate you about something so that now you have the knowledge you need to go forward? Or was it really just a way to get you to become a client?” he asks. “Because if it’s the latter, then walk out the door the minute the speaker tries to sell you something. If the purpose is to sell you something, you’ve got to be suspect about everything that person says.”

Investigate seminar leaders just as you would research devices or consultants. “See what the person has done,” Dr. Perle says. “What have they published? If it’s a book, forget it. If it’s an article in some chiropractic magazine, forget it. I want to know if they’ve published in peer-reviewed scientific literature. There are people in the seminar business of teaching you stuff that makes you happy. That’s OK. If their job is to make you feel good, then consider it personal development and go ahead. But don’t consider it continuing education.”

Finally, if you have been duped by a snake oil salesman, chalk it up as a lesson learned, advises Dr. Feinberg. Then don’t be shy about sharing what you’ve learned.

“Tell your colleagues,” he says. “When we chiropractors learn about a great technique, something valuable, we need to share that. And if we’ve been duped by something we discover is worthless, it’s even more important to share that information.”
 

ACA News Extra...

Billing for Equipment and Supplies
To bill for medical equipment and supplies, providers should use the Healthcare Common Procedure Coding System (HCPCS)—a set of health care procedure codes based on AMA’s Current Procedural Terminology® (CPT). HCPCS was established in 1978 as a standardized coding system for describing the specific items and services provided in the delivery of health care. However, while HCPCS is a standardized coding system, it can often be confusing to determine which code applies to which supplies.

When selecting the appropriate HCPCS code for equipment and supplies, don’t just rely on the manufacturer to provide you with the correct code. Doctors often bill with the manufacturer’s recommendation—only to find it is not accepted by the insurer.

To ensure you are using the appropriate HCPCS code, ACA recommends the following:

1. Do your research. Review a coding manual that keeps up with changes in the HCPCS codes, such as ACA’s Chiropractic Coding and Compliance Manual, to verify that it concurs with the manufacturer’s suggestion.
2. Contact the insurer. The insurer may have a specific code it would prefer to be used and/or reimbursement policies you should be aware of prior to billing for the equipment, device or supply.
3. ACA members can contact ACA’s Insurance Relations department. If your research does not produce a definitive answer, you can e-mail the question for review to ACA’s Insurance Relations department at insinfo@acatoday.org.