Integrated Physical Medicine Models

[Jeremy G]

I work in one of these integrated models, which is owned by 2 chiropractors, and have many ethical and moral concerns about the billing aspect. I realize the good intensions of these models but there are some real flaws. Here's our model:

NP, DC, PT

New patients see the NP (me), I do the initial exam and order x-rays if needed, the patient then goes over to get their x-rays, then the DC sees them for a "brief palpation exam" (problem 1- this is ok since when they are scheduled they know they are going to see the NP and the DC that day. However, this may appear to be a conflict of interest), then the patient is checked out up front. Then there is this team meeting to discuss every patient we saw as a group (NP, DC, PT, MA, case manager) the day before (problem 2 - hippa compliance) On day 2 they return to go over x-rays with me, treatment recommendations, and financial responsibilities (in a meeting room), our case manager and NP sits with them and lets them decide how they want to proceed. After this "Day 2 x-ray review" we then take them to either their first PT appointment or their first DC appointment. Currently, nothing is billed for the x-ray review. Once these first 2 days are done they begin usually twice per week visits with us. These visits are may involve 45 min of PT, 15 min with DC, and 5 min with NP for say trigger point injections (tpi typically once per week). And these latter visits occur weekly. However, I'm being told from the owner, who is a chiropractor, that I am supposed to perform a re-exam (99213) every 30 days on these patients (I challenge this!). This to me is clearly a way to continuously bill a 99213 to their insurance until they are discharged or quit coming. Before this, I worked for orthopedic surgeons for 8 years. Never have I heard a physician being required to see a PT or Chiro patient every 30 days in order to "authorize continued visits. " If I write a script for a patient to have PT for 8 weeks at 2 times a week, the PT is perfectly capable to evaluate these patients and send me or the physician updates. We NP and physicians do not have to re-examine these patients as this would clearly be "overtreatment" and "excessive unnecessary billing". However, our owner, the chiropractor, does not agree.

Problem 1- what if the NP did not order chiropractic eval and treat and the DC just goes in and starts touching them all over. Hello. Privacy. Of course, I'm not sure what these patients sign when they come through our door. Some of my patient clearly do not want to see the chiropractor. Of course we have many scheduling issues to .

Problem 2- team meeting? Total waste of time for the NP. But that's a side note. How about HIPPA violation. Who's in these meetings? I the NP do not need to hear about a chiro patient that is not my patient nor does the PT need to hear about one of my patients that I am not sending to PT. I realize HIPPA is broken every day but I am trying to argue that this system can work without violating HIPPA and still achieve the same goal. Also, as the NP we are being forced by owners to order services that we may not feel is appropriate. I realize the owner signs my paycheck and I could care less. I get very tired of my license being used by others for their self-gain.

I would like to hear clear evidence as to why patients in this model need to go back to the NP every 30 days for a re-exam. Based on what? And I don't want answers about this being a way to support my salary.

[PG2018]

I think chiro is a total sham. Of course, it's all money driven. Every clinic is.

[Psychcns]

It sounds like you don't think they need to be reevaluated by you every thirty days. Then don't do it. If you think you are over treating then you are.

Re:the team meeting. What is the purpose of it? Who needs to be there and why? Could be a hipaa violation. In any case sounds like you think it is a waste of time for you.

Doesn't sound like the job is a good fit for you

[penniv]

Jeremy,

I have spent the 5 years in Orthopaedic Surgery. Prior to that I tried my hand at the Chiro/Medical model. I found out very quickly that it was all about making the DC money and not about helping my medical patients. My DC was insisting that I perform US guided arthrocentesis at least 5x/day. When I pushed back and said there was no way that my patients needed that he insisted that it was necessary to cover my salary. I threatened to report him to CMS for fraudulent billing and that settled him down!

You will not find proof about the need to see patients every 30 days because it doesn't exist. It is a billing tactic used to create income. I caution NPs to avoid getting into this type of system unless it is run by a MD and not a DC.

Penni